Healthcare Provider Details

I. General information

NPI: 1609660638
Provider Name (Legal Business Name): RYAN NAZARENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

275 MICHIGAN ST NE STE 9TH FLOOR
GRAND RAPIDS MI
49503-2531
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax: 616-391-8897
Mailing address:
  • Phone: 616-391-3777
  • Fax: 616-391-3755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351054557
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4351054557
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: