Healthcare Provider Details

I. General information

NPI: 1588629703
Provider Name (Legal Business Name): MIRIAM BENEDICTA VOS MD, MSPH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MIRIAM VOS LOUTHAN MD, MSPH

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MICHIGAN ST NE STE 4150
GRAND RAPIDS MI
49503-2529
US

IV. Provider business mailing address

959 PINECREST AVE SE
GRAND RAPIDS MI
49506-3436
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-4100
  • Fax:
Mailing address:
  • Phone: 404-803-7733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number54160
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: