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General NPI Number Information
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NPI Number | 1043075294
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Entity Type | Organization
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Legal Business Name | ADDRESS HEALTHCARE OF MICHIGAN PLLC
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Dates
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Enumeration Date | 02/16/2024
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Last Update Date | 05/05/2025
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Provider Practice Location Address
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Address Line | 600 MONROE AVENUE NW STE 104
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-1470
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Country | US
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Telephone | 616-366-4234
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Fax | 855-548-4481
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Provider Business Mailing Address
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Address Line | 3940 PENINSULAR DRIVE SE STE 230
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-2442
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Country | US
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Telephone | 616-366-4234
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Fax | 855-548-4481
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | JEFFREY L WACKSMAN
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Credential |
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Telephone | 616-366-4234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RH0002X
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Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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