Healthcare Provider Details

I. General information

NPI: 1750002622
Provider Name (Legal Business Name): ANTHONY WOODARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 WEALTHY ST SE
GRAND RAPIDS MI
49506-2921
US

IV. Provider business mailing address

6069 RIDGEVIEW DR
NORTON SHORES MI
49441-6143
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-7444
  • Fax:
Mailing address:
  • Phone: 231-670-7408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501301842
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: