Healthcare Provider Details

I. General information

NPI: 1114034162
Provider Name (Legal Business Name): KYLE A RASIKAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
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: 616-685-5000
  • Fax:
Mailing address:
  • Phone: 616-685-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301041661
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301041661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: