Healthcare Provider Details

I. General information

NPI: 1033341888
Provider Name (Legal Business Name): SUBODH JAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 E BELTLINE AVE NE FL 3
GRAND RAPIDS MI
49525-8614
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-447-5820
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301502237
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: