Healthcare Provider Details

I. General information

NPI: 1336633742
Provider Name (Legal Business Name): DEXTER ROBERT MCKELLAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 WILSON AVE NW
WALKER MI
49534-6407
US

IV. Provider business mailing address

300 LAFAYETTE AVE SE STE 4000
GRAND RAPIDS MI
49503-4692
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8650
  • Fax: 616-791-2160
Mailing address:
  • Phone: 616-685-5922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351041142
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301115644
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301502149
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: