Healthcare Provider Details

I. General information

NPI: 1972869048
Provider Name (Legal Business Name): LEE PATRICK HEERINGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GRANDVILLE AVE SW
GRAND RAPIDS MI
49503-4920
US

IV. Provider business mailing address

1900 44TH ST SE
KENTWOOD MI
49508-5008
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8400
  • Fax: 616-742-1322
Mailing address:
  • Phone: 616-685-1808
  • Fax: 616-685-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301109096
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: