Healthcare Provider Details

I. General information

NPI: 1780642355
Provider Name (Legal Business Name): GRAND RAPIDS ADDICTION MEDICINE SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE DR SE SUITE 305
GRAND RAPIDS MI
49546-8292
US

IV. Provider business mailing address

PO BOX 1682
GRAND RAPIDS MI
49501-1682
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-0600
  • Fax: 616-954-1675
Mailing address:
  • Phone: 616-954-0600
  • Fax: 616-954-1675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301047295
License Number StateMI

VIII. Authorized Official

Name: KHAN JAVAN NEDD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 616-954-0600