Healthcare Provider Details

I. General information

NPI: 1477784056
Provider Name (Legal Business Name): CHRISTINA BAKALIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BYRON CENTER AVE SW
WYOMING MI
49519
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW MEDICAL ADMINISTRATION
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-7837
  • Fax: 616-252-6939
Mailing address:
  • Phone: 616-252-7837
  • Fax: 616-252-6939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301095360
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberQ6145
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301095360
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301095360
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: