Healthcare Provider Details

I. General information

NPI: 1023471422
Provider Name (Legal Business Name): ALISSA ENZENBERGER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 FOREST HILL AVE SE
GRAND RAPIDS MI
49546-2380
US

IV. Provider business mailing address

877 FOREST HILL AVE SE
GRAND RAPIDS MI
49546-2380
US

V. Phone/Fax

Practice location:
  • Phone: 616-402-2618
  • Fax:
Mailing address:
  • Phone: 616-949-4465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301500484
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: