Healthcare Provider Details

I. General information

NPI: 1083149173
Provider Name (Legal Business Name): MADELINE JANELLE GINN-TERPSTRA D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 EAGLE RUN DR NE STE 103
GRAND RAPIDS MI
49525-7069
US

IV. Provider business mailing address

804 SERVICE RD STE A109B
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 616-234-2830
  • Fax: 517-234-2829
Mailing address:
  • Phone: 616-234-2830
  • Fax: 616-234-2829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number5101025735
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: