Healthcare Provider Details

I. General information

NPI: 1518253566
Provider Name (Legal Business Name): KELSEY MAE COPUS D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

V. Phone/Fax

Practice location:
  • Phone: 734-845-0448
  • Fax:
Mailing address:
  • Phone: 734-845-0448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5101019195
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: