Healthcare Provider Details

I. General information

NPI: 1568490837
Provider Name (Legal Business Name): MICHAEL P. BUETOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-2315
  • Fax: 517-372-1617
Mailing address:
  • Phone: 616-363-7339
  • Fax: 616-361-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301066029
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: