Healthcare Provider Details

I. General information

NPI: 1922022409
Provider Name (Legal Business Name): CHRISTOPHER CLARK MASSIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

PO BOX 5329
SAGINAW MI
48603-0329
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6200
  • Fax:
Mailing address:
  • Phone: 616-364-6700
  • Fax: 989-401-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number5101012108
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number5101012108
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5101012108
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: