Healthcare Provider Details

I. General information

NPI: 1003909524
Provider Name (Legal Business Name): MFB PROFESSIONAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 E. PARIS, STE 200
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

235 WEALTHY SE
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-233-3480
  • Fax: 616-233-3481
Mailing address:
  • Phone: 616-242-0300
  • Fax: 616-235-3997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number4301059802
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301042627
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDALL L. DENEFF
Title or Position: VP FINANCE
Credential:
Phone: 616-242-0403