Healthcare Provider Details

I. General information

NPI: 1811347966
Provider Name (Legal Business Name): KSENIYA BEZPALKO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE SUITE 300
GRAND RAPIDS MI
49503-2556
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC013
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax:
Mailing address:
  • Phone: 616-267-0075
  • Fax: 616-267-0090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301109962
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: