Healthcare Provider Details

I. General information

NPI: 1952434292
Provider Name (Legal Business Name): BRUCE D DRAGOO MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE SUITE 225
GRAND RAPIDS MI
49546-3691
US

IV. Provider business mailing address

1000 E PARIS AVE SE SUITE 225
GRAND RAPIDS MI
49546-3691
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-3643
  • Fax: 616-957-0896
Mailing address:
  • Phone: 616-957-3643
  • Fax: 616-957-0896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4301028716
License Number StateMI

VIII. Authorized Official

Name: FREDA LYN LARKIN
Title or Position: BILLING
Credential:
Phone: 616-957-3643