Healthcare Provider Details

I. General information

NPI: 1841368651
Provider Name (Legal Business Name): KONSTANTIN VOLOD ELISEVICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE SUITE 6100
GRAND RAPIDS MI
49503-2515
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-267-7900
  • Fax: 616-267-7901
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number060725
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: