Healthcare Provider Details

I. General information

NPI: 1740243856
Provider Name (Legal Business Name): PETER JEFFREY VANCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 BROADMOOR AVE SE
KENTWOOD MI
49512-5302
US

IV. Provider business mailing address

743 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-6045
US

V. Phone/Fax

Practice location:
  • Phone: 616-952-4200
  • Fax:
Mailing address:
  • Phone: 616-300-0096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPV077860
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: