Healthcare Provider Details

I. General information

NPI: 1932227915
Provider Name (Legal Business Name): WESTERN MICHIGAN PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KENMOOR AVE SE SUITE 110
GRAND RAPIDS MI
49546-2379
US

IV. Provider business mailing address

721 KENMOOR AVE SE
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-6112
  • Fax: 616-949-8530
Mailing address:
  • Phone: 616-949-6112
  • Fax: 616-949-8530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L VAN ZEE
Title or Position: TREASURER
Credential: M.D.
Phone: 616-949-6112