Healthcare Provider Details

I. General information

NPI: 1689640237
Provider Name (Legal Business Name): GARY K RALPH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 ORCHARD VISTA DR SE
GRAND RAPIDS MI
49546-7069
US

IV. Provider business mailing address

3075 ORCHARD VISTA DR SE
GRAND RAPIDS MI
49546-7069
US

V. Phone/Fax

Practice location:
  • Phone: 616-301-8000
  • Fax:
Mailing address:
  • Phone: 616-301-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101010873
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: