Healthcare Provider Details

I. General information

NPI: 1598865735
Provider Name (Legal Business Name): MICHIGAN INSTITUTE OF UROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE SUITE 3300
GRAND RAPIDS MI
49503-2515
US

IV. Provider business mailing address

25 MICHIGAN ST NE STE 3300
GRAND RAPIDS MI
49503-2558
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-4171
  • Fax: 616-459-0044
Mailing address:
  • Phone: 616-459-4171
  • Fax: 616-459-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: TRACY MCAULEY
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 586-771-4820