Healthcare Provider Details

I. General information

NPI: 1689419087
Provider Name (Legal Business Name): BROOKE ELIZABETH WIETHARN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6922
  • Fax: 616-685-5101
Mailing address:
  • Phone: 616-685-6922
  • Fax: 616-685-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351055055
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2024025232
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: