Healthcare Provider Details

I. General information

NPI: 1629428552
Provider Name (Legal Business Name): JUSTIN RIETH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE SUITE 2100
GRAND RAPIDS MI
49503-2515
US

IV. Provider business mailing address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3777
  • Fax:
Mailing address:
  • Phone: 616-486-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301110228
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: