Healthcare Provider Details

I. General information

NPI: 1649626508
Provider Name (Legal Business Name): LUKE EASTBURG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 FOREMOST DR SE STE 200
GRAND RAPIDS MI
49546-7062
US

IV. Provider business mailing address

5800 FOREMOST DR SE STE 200
GRAND RAPIDS MI
49546-7062
US

V. Phone/Fax

Practice location:
  • Phone: 616-389-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number301369
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number4301511990
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number301369
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: