Healthcare Provider Details

I. General information

NPI: 1336261395
Provider Name (Legal Business Name): GARY DAVID POELMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 EAGLE PARK DR NE STE103
GRAND RAPIDS MI
49525-7004
US

IV. Provider business mailing address

3713 NORTON HILLS RD
NORTON SHORES MI
49441-4469
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberGP043454
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberGP043454
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberGP043454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: