Healthcare Provider Details

I. General information

NPI: 1073205365
Provider Name (Legal Business Name): ALEXA MAGSOUDI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 05/24/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE 300 68TH ST SE
GRAND RAPIDS MI
49548
US

IV. Provider business mailing address

300 68TH ST SE 300 68TH ST SE
GRAND RAPIDS MI
49548
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-0857
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5151016041
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: