Healthcare Provider Details

I. General information

NPI: 1043836612
Provider Name (Legal Business Name): JACOB ICEBERG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 60TH ST SE # 200
GRAND RAPIDS MI
49548-8504
US

IV. Provider business mailing address

280 60TH ST SE # 200
GRAND RAPIDS MI
49548-8504
US

V. Phone/Fax

Practice location:
  • Phone: 616-483-0750
  • Fax:
Mailing address:
  • Phone: 616-483-0750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101026922
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: