Healthcare Provider Details

I. General information

NPI: 1639116122
Provider Name (Legal Business Name): DOUGLAS E HENRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

IV. Provider business mailing address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

V. Phone/Fax

Practice location:
  • Phone: 616-840-8005
  • Fax: 616-840-9642
Mailing address:
  • Phone: 616-840-8877
  • Fax: 616-840-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number35072544
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number4301054794
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: