Healthcare Provider Details

I. General information

NPI: 1043310212
Provider Name (Legal Business Name): JOSEPH TAYLOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 O'BRIEN ROAD SW
GRAND RAPIDS MI
49544
US

IV. Provider business mailing address

3250 O'BRIEN ROAD SW
GRAND RAPIDS MI
49544
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-5383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301025980
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: