Healthcare Provider Details

I. General information

NPI: 1992142624
Provider Name (Legal Business Name): JEREMY ROBERT VEENEMA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 06/16/2016
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

2125 NEGAUNEE DR SE
GRAND RAPIDS MI
49506-5318
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-6112
  • Fax: 616-949-8530
Mailing address:
  • Phone: 616-443-6958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125062773
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: