Healthcare Provider Details

I. General information

NPI: 1467415372
Provider Name (Legal Business Name): GAIL K BRYAN-BESTEMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 44TH ST SW
WYOMING MI
49519-6439
US

IV. Provider business mailing address

1925 BRETON RD SE
GRAND RAPIDS MI
49506-4810
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-8300
  • Fax: 616-252-8460
Mailing address:
  • Phone: 616-252-4765
  • Fax: 616-252-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101078419
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: