Healthcare Provider Details

I. General information

NPI: 1780321679
Provider Name (Legal Business Name): BRIAN MATTHEW KREISMAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 07/30/2023
Certification Date: 07/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 BRETON RD SE
GRAND RAPIDS MI
49512-1745
US

IV. Provider business mailing address

2848 BELLEGLADE CT SE
GRAND RAPIDS MI
49546-8011
US

V. Phone/Fax

Practice location:
  • Phone: 616-914-2020
  • Fax:
Mailing address:
  • Phone: 616-914-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1601000622
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: