Healthcare Provider Details

I. General information

NPI: 1558892265
Provider Name (Legal Business Name): MELISSA PAVELACK GOLDEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA PAVELACK DO

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-1526
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number5101028320
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: