Healthcare Provider Details

I. General information

NPI: 1083503866
Provider Name (Legal Business Name): THWAB FREIHAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2025
Last Update Date: 06/28/2025
Certification Date: 06/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MICHIGAN ST NE 8TH FLOOR
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

275 MICHIGAN ST NE 8TH FLOOR
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax: 616-391-8897
Mailing address:
  • Phone: 616-391-8810
  • Fax: 616-391-8897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351054399
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: