Healthcare Provider Details

I. General information

NPI: 1164594420
Provider Name (Legal Business Name): JAMES E HOOGEBOOM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6290 BURTON ST SE
GRAND RAPIDS MI
49546-6775
US

IV. Provider business mailing address

6290 BURTON ST SE
GRAND RAPIDS MI
49546-6775
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-7768
  • Fax: 616-975-7769
Mailing address:
  • Phone: 616-975-7768
  • Fax: 616-975-7769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberCL0065
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number5101008395
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: