Healthcare Provider Details

I. General information

NPI: 1932170065
Provider Name (Legal Business Name): RICHARD A AXTELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE MC 249
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-1925
  • Fax: 616-267-1005
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number4301048203
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: