Healthcare Provider Details

I. General information

NPI: 1487276960
Provider Name (Legal Business Name): DYLAN CONNOR GOLDSMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE # 601A
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

8000 JUDGE BLVD
LOUISVILLE KY
40219-3915
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-6243
  • Fax:
Mailing address:
  • Phone: 502-930-1544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4351049524
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: