Healthcare Provider Details

I. General information

NPI: 1629090907
Provider Name (Legal Business Name): TODD A PRYOR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 WASHINGTON ST
LAKEVIEW MI
48850-9806
US

IV. Provider business mailing address

PO BOX 3567
GRAND RAPIDS MI
49501-3567
US

V. Phone/Fax

Practice location:
  • Phone: 989-352-7211
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax: 616-285-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101009393
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5101009393
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: