Healthcare Provider Details

I. General information

NPI: 1639359029
Provider Name (Legal Business Name): LYNN S HEDEMAN, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505-6038
US

IV. Provider business mailing address

414 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505-6038
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-3465
  • Fax: 616-454-9004
Mailing address:
  • Phone: 616-454-3465
  • Fax: 616-454-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number4301029420
License Number StateMI

VIII. Authorized Official

Name: LYNN STUART HEDEMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 616-454-3465