Healthcare Provider Details

I. General information

NPI: 1619147493
Provider Name (Legal Business Name): JOANNE MARIE GRZESZAK DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 ALGER ST SE
GRAND RAPIDS MI
49507-3803
US

IV. Provider business mailing address

4310 LEONARD ST NW SUITE 103
WALKER MI
49534-8447
US

V. Phone/Fax

Practice location:
  • Phone: 616-452-8923
  • Fax:
Mailing address:
  • Phone: 616-453-6329
  • Fax: 616-453-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number00714
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JOANNE M GRZESZAK
Title or Position: PROVIDER
Credential: DO
Phone: 616-452-8923