=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447663844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARRETT CALDWELL DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2014
-----------------------------------------------------
Last Update Date | 08/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 781 36TH ST SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49548-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-252-4100
-----------------------------------------------------
Fax | 616-252-4953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5900 BYRON CENTER AVE SW MEDICAL ADMINISTRATION
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49519-9606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-252-3243
-----------------------------------------------------
Fax | 616-252-0260
-----------------------------------------------------
=====================================================
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 | OT015956
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101024374
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------