Healthcare Provider Details

I. General information

NPI: 1558320481
Provider Name (Legal Business Name): KARL BRIAN ROMANESCHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4069 LAKE DR SE STE 315
GRAND RAPIDS MI
49546-8816
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-7758
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301510537
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: