Healthcare Provider Details

I. General information

NPI: 1275748121
Provider Name (Legal Business Name): COURTNEY ANN SOUBLIERE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY ANN CASTLE

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE SE STE 2045
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

245 STATE ST SE STE 228
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-3098
  • Fax: 616-685-3095
Mailing address:
  • Phone: 616-685-1808
  • Fax: 616-685-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number5101015706
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: