Healthcare Provider Details

I. General information

NPI: 1780265561
Provider Name (Legal Business Name): BENJAMIN DANIEL TIFT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15100 WHITTAKER WAY
GRAND HAVEN MI
49417-8696
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-935-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101027808
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: