Healthcare Provider Details

I. General information

NPI: 1699707380
Provider Name (Legal Business Name): TAMARA SPRINGBERG P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMARA SPRINGBERG P.A.C.

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 CASCADE RD SE
GRAND RAPIDS MI
49546-2149
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW MEDICAL ADMINISTRATION
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-5760
  • Fax: 616-252-3608
Mailing address:
  • Phone: 616-252-3243
  • Fax: 616-252-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005158
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: