Healthcare Provider Details

I. General information

NPI: 1124129689
Provider Name (Legal Business Name): JAMES MICHAEL CARL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2488 HIGHRIDGE HILLS LN. SE
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

2488 HIGHRIDGE HILLS LN. SE
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 816-665-3783
  • Fax:
Mailing address:
  • Phone: 816-665-3783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101006719
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number34345
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: