=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336590843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARA JEAN BAATENBURG MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2016
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6741 FULTON ST E STE 200
-----------------------------------------------------
City | ADA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49301-9502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-290-1650
-----------------------------------------------------
Fax | 833-973-4117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 36TH ST SW
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49509-3587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-685-3300
-----------------------------------------------------
Fax | 616-685-3303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4301109996
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------