Healthcare Provider Details

I. General information

NPI: 1093577108
Provider Name (Legal Business Name): ADO MEDICAL OF KANSAS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4555 WILSON AVE SW STE 1
GRANDVILLE MI
49418-2370
US

IV. Provider business mailing address

625 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 616-229-2935
  • Fax:
Mailing address:
  • Phone: 616-229-2935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TIM GUTWALD
Title or Position: GENERAL COUNSEL
Credential:
Phone: 616-498-8102