Healthcare Provider Details

I. General information

NPI: 1215902481
Provider Name (Legal Business Name): PETER B HERKNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LAFAYETTE AVE SE SUITE 308
GRAND RAPIDS MI
49503-4656
US

IV. Provider business mailing address

350 LAFAYETTE AVE SE SUITE 308
GRAND RAPIDS MI
49503-4656
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-9925
  • Fax: 616-451-9896
Mailing address:
  • Phone: 616-451-9925
  • Fax: 616-451-9896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301039334
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: