Healthcare Provider Details

I. General information

NPI: 1285687467
Provider Name (Legal Business Name): FREDRIC ALAN REYELTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY AVE NW STE 105
GRAND RAPIDS MI
49504-4496
US

IV. Provider business mailing address

801 BROADWAY AVE NW STE 105
GRAND RAPIDS MI
49504-4496
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-7500
  • Fax: 616-785-7511
Mailing address:
  • Phone: 616-685-7500
  • Fax: 616-685-7511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301051511
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number4301051511
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301051511
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: