Healthcare Provider Details

I. General information

NPI: 1326096975
Provider Name (Legal Business Name): SARAH NICOLE ELMOUCHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 CASCADE RD SE SUITE B
GRAND RAPIDS MI
49546-3794
US

IV. Provider business mailing address

5150 CASCADE RD SE SUITE B
GRAND RAPIDS MI
49546-3794
US

V. Phone/Fax

Practice location:
  • Phone: 616-940-3168
  • Fax: 616-940-3352
Mailing address:
  • Phone: 616-940-3168
  • Fax: 616-940-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301079696
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: