Healthcare Provider Details

I. General information

NPI: 1457934424
Provider Name (Legal Business Name): EMMANUEL JOHN BART-PLANGE IV PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE STE 6100
GRAND RAPIDS MI
49503-2561
US

IV. Provider business mailing address

3290 W BIG BEAVER RD STE 150
TROY MI
48084-2931
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-7900
  • Fax:
Mailing address:
  • Phone: 248-792-6527
  • Fax: 248-792-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010541
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7968
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: