Healthcare Provider Details

I. General information

NPI: 1689848459
Provider Name (Legal Business Name): BRANDON D ELLSWORTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

PO BOX 1629
LIMA OH
45802-1629
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-6700
  • Fax:
Mailing address:
  • Phone: 877-378-4293
  • Fax: 419-223-2726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301102483
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: