Healthcare Provider Details

I. General information

NPI: 1629024583
Provider Name (Legal Business Name): KEVIN MCBRIDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 WILSON AVE NW
WALKER MI
49534-3493
US

IV. Provider business mailing address

245 STATE ST SE
GRAND RAPIDS MI
49503-4328
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8650
  • Fax: 616-791-2160
Mailing address:
  • Phone: 616-685-1808
  • Fax: 616-685-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301044990
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: