Healthcare Provider Details

I. General information

NPI: 1326649120
Provider Name (Legal Business Name): SOURCE MEDICAL SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 01/23/2022
Certification Date: 01/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-2395
US

IV. Provider business mailing address

625 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-8063
  • Fax:
Mailing address:
  • Phone: 616-916-8063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS HENKE
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 616-916-8063