Healthcare Provider Details

I. General information

NPI: 1770016636
Provider Name (Legal Business Name): ALEXANDRA MARIE MENILLO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE STE 4200
GRAND RAPIDS MI
49503-2559
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-9150
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101026148
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number5101026148
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: