Healthcare Provider Details

I. General information

NPI: 1972960060
Provider Name (Legal Business Name): WILLIAM G MARTIN R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 LEONARD ST NE
GRAND RAPIDS MI
49505-5515
US

IV. Provider business mailing address

755 36TH ST SE BUILDING 1
GRAND RAPIDS MI
49548-2319
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-8789
  • Fax: 616-776-1305
Mailing address:
  • Phone: 616-726-5104
  • Fax: 616-301-8011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704213367
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: