Healthcare Provider Details

I. General information

NPI: 1275527053
Provider Name (Legal Business Name): DERMATOLOGY CENTER OF GRAND RAPIDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E BELTLINE AVE NE SUITE 301
GRAND RAPIDS MI
49525-6049
US

IV. Provider business mailing address

750 E BELTLINE AVE NE SUITE 301
GRAND RAPIDS MI
49525-6049
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-9343
  • Fax: 616-942-2538
Mailing address:
  • Phone: 616-942-9343
  • Fax: 616-942-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EVELYN E VANDERVEEN
Title or Position: PRESIDENT
Credential: MD
Phone: 616-942-9343