Healthcare Provider Details

I. General information

NPI: 1033771746
Provider Name (Legal Business Name): IBRAHIM RAZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE SUITE 3000
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

300 LAFAYETTE AVE SE SUITE 3000
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-4615
  • Fax:
Mailing address:
  • Phone: 616-685-4615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD-49271
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4351045550
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: