Healthcare Provider Details

I. General information

NPI: 1487612610
Provider Name (Legal Business Name): TERRENCE J EMILEY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1238 FULLER AVE NE
GRAND RAPIDS MI
49505-5533
US

IV. Provider business mailing address

4310 LEONARD ST NW SUITE 103
WALKER MI
49534-8447
US

V. Phone/Fax

Practice location:
  • Phone: 616-452-0467
  • Fax: 616-452-8885
Mailing address:
  • Phone: 616-453-6329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5901000775
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901000775
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: