Healthcare Provider Details

I. General information

NPI: 1114917226
Provider Name (Legal Business Name): ELLEN MARIE KRUGGEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 BRETON RD SE SUITE 103
KENTWOOD MI
49508-5262
US

IV. Provider business mailing address

4600 BRETON RD SE SUITE 103
KENTWOOD MI
49508-5262
US

V. Phone/Fax

Practice location:
  • Phone: 616-656-8600
  • Fax: 616-656-8601
Mailing address:
  • Phone: 616-656-8600
  • Fax: 616-656-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301067448
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: