Healthcare Provider Details

I. General information

NPI: 1174142285
Provider Name (Legal Business Name): JEREMY DAVID MORMOL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

1153 ARLINGTON ST NE
GRAND RAPIDS MI
49505-3807
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-6243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4351046796
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: