Healthcare Provider Details

I. General information

NPI: 1659931996
Provider Name (Legal Business Name): SAMANTHA WILLIAMS AL-KHARUSY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA S AL-KHARUSY MD

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 KENMOOR AVE SE
GRAND RAPIDS MI
49546-2306
US

IV. Provider business mailing address

721 KENMOOR AVE SE
GRAND RAPIDS MI
49546-2306
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-6112
  • Fax: 616-949-8530
Mailing address:
  • Phone: 616-949-6112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number7761851
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number75134
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number75134-20
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301509221
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: