Healthcare Provider Details

I. General information

NPI: 1427027861
Provider Name (Legal Business Name): JAMES M. WYNALDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 BROOKVILLE PLAZA SE
GRAND RAPIDS MI
49508
US

IV. Provider business mailing address

8485 ALGOMA AVE P.O.BOX 346
ROCKFORD MI
49341
US

V. Phone/Fax

Practice location:
  • Phone: 616-243-5707
  • Fax: 616-243-1170
Mailing address:
  • Phone: 616-863-6220
  • Fax: 616-863-6221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301053498
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: