Healthcare Provider Details

I. General information

NPI: 1295174076
Provider Name (Legal Business Name): HEATHER MARIE KLINGEMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER MARIE SIRKO MD

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MICHIGAN ST NE STE 200
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC-845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-8950
  • Fax: 616-267-8585
Mailing address:
  • Phone: 616-267-8950
  • Fax: 616-267-8585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number58087
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number4301109320
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: