Healthcare Provider Details

I. General information

NPI: 1629115886
Provider Name (Legal Business Name): REBECCA J. HUIZEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA EVERHART

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 918-391-3670
  • Fax:
Mailing address:
  • Phone: 918-391-3670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4445
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: