Healthcare Provider Details

I. General information

NPI: 1659583888
Provider Name (Legal Business Name): CYPRIAN A GARDINE III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE STE 2045
GRAND RAPIDS MI
49503-4692
US

IV. Provider business mailing address

1900 44TH ST SE
KENTWOOD MI
49508-5008
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number4301106353
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: