Healthcare Provider Details

I. General information

NPI: 1780676551
Provider Name (Legal Business Name): THEODORE A DORSEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 HOLTON RD
N MUSKEGON MI
49445-1578
US

IV. Provider business mailing address

100 MICHIGAN STREET NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 231-291-8399
  • Fax: 231-291-8397
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002357
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: