Healthcare Provider Details

I. General information

NPI: 1437187416
Provider Name (Legal Business Name): MICHELLE M. CONDON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE A721
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3139
  • Fax: 616-391-3044
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4301042339
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301042339
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: