Healthcare Provider Details

I. General information

NPI: 1720292303
Provider Name (Legal Business Name): GYNECOLOGIC ONCOLOGY OF WEST MICHIGAN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE SUITE 242
GRAND RAPIDS MI
49546-3691
US

IV. Provider business mailing address

1000 E PARIS AVE SE SUITE 242
GRAND RAPIDS MI
49546-3691
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-3398
  • Fax:
Mailing address:
  • Phone: 616-957-3398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTI KNOX DOWNEY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 616-957-3539