Healthcare Provider Details

I. General information

NPI: 1487967733
Provider Name (Legal Business Name): JOHANNA R KREBIEHL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2543
US

IV. Provider business mailing address

341 HOBART ST SE
GRAND RAPIDS MI
49507-3140
US

V. Phone/Fax

Practice location:
  • Phone: 248-703-5269
  • Fax:
Mailing address:
  • Phone: 248-703-5269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301096903
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: