=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376807933
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN MICHAEL DAVIES M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2012
-----------------------------------------------------
Last Update Date | 12/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3355 EAGLE PARK DR NE STE 103
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-7004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-942-7400
-----------------------------------------------------
Fax | 616-942-7405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 639295 DEPT 93394
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-9295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-346-1692
-----------------------------------------------------
Fax | 556-186-6558
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 4301101550
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------