Healthcare Provider Details

I. General information

NPI: 1922155332
Provider Name (Legal Business Name): JOHN A WALEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 LAFAYETTE AVE NE
GRAND RAPIDS MI
49505-5092
US

IV. Provider business mailing address

1211 LAFAYETTE AVE NE
GRAND RAPIDS MI
49505-5092
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-8800
  • Fax: 616-336-9700
Mailing address:
  • Phone: 616-336-8800
  • Fax: 616-336-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301045167
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: