Healthcare Provider Details

I. General information

NPI: 1366540064
Provider Name (Legal Business Name): GRAND RAPIDS VEIN CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2018
US

IV. Provider business mailing address

1720 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2018
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-8442
  • Fax:
Mailing address:
  • Phone: 616-454-8442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH B MAROGIL
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 616-454-8442