Healthcare Provider Details

I. General information

NPI: 1003816224
Provider Name (Legal Business Name): TAMMY BORN HUIZENGA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMMY L BORN D.O

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 52ND ST SE
GRAND RAPIDS MI
49512-9637
US

IV. Provider business mailing address

3700 52ND ST SE
GRAND RAPIDS MI
49512-9637
US

V. Phone/Fax

Practice location:
  • Phone: 616-656-3700
  • Fax: 616-656-3701
Mailing address:
  • Phone: 616-656-3700
  • Fax: 616-656-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTB009726
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: