Healthcare Provider Details

I. General information

NPI: 1063277796
Provider Name (Legal Business Name): GRAND TRAVERSE ORTHOPEDICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5246 N ROYAL DR
TRAVERSE CITY MI
49684-6984
US

IV. Provider business mailing address

5246 N ROYAL DR
TRAVERSE CITY MI
49684-6984
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0957
  • Fax:
Mailing address:
  • Phone: 231-935-0957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN C BRYANT
Title or Position: MEMBER
Credential: DPM
Phone: 231-935-0957