Healthcare Provider Details

I. General information

NPI: 1174761837
Provider Name (Legal Business Name): WASSIM IBRAHIM JAWAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRADFORD ST NE
GRAND RAPIDS MI
49525-6427
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-885-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301111471
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number4301111471
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: