Healthcare Provider Details

I. General information

NPI: 1407475049
Provider Name (Legal Business Name): BRIAN GERAGHTY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

PO BOX 744785
ATLANTA GA
30374-4785
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number5101028031
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: