Healthcare Provider Details

I. General information

NPI: 1396002796
Provider Name (Legal Business Name): GRACE INGRAM NEWMAN BS, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACE CHRISTIAN INGRAM BS, MD

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-7272
  • Fax: 616-361-5828
Mailing address:
  • Phone: 616-363-7272
  • Fax: 616-361-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301512893
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number57364
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25685
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME169786
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: