Healthcare Provider Details

I. General information

NPI: 1770062630
Provider Name (Legal Business Name): ALEJANDRA MARIA ESCOBAR VASCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2018
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE STE 300
GRAND RAPIDS MI
49503-2527
US

IV. Provider business mailing address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax: 616-391-8897
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301116105
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number75236-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: