Healthcare Provider Details

I. General information

NPI: 1063690840
Provider Name (Legal Business Name): JOHN A MULDER, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BROADWAY AVE NW #423
GRAND RAPIDS MI
49504-7305
US

IV. Provider business mailing address

600 BROADWAY AVE NW #423
GRAND RAPIDS MI
49504-7305
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-4593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number4301043859
License Number StateMI

VIII. Authorized Official

Name: JOHN MULDER
Title or Position: PRESIDENT
Credential: MD
Phone: 616-451-4593