Healthcare Provider Details

I. General information

NPI: 1356557896
Provider Name (Legal Business Name): PHILLIP A RADUAZO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-7339
  • Fax: 616-361-5828
Mailing address:
  • Phone: 616-363-7339
  • Fax: 616-361-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberM6837
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number2010-00344
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301111326
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: