=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578305637
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW L DEGROOT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2024
-----------------------------------------------------
Last Update Date | 06/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 MICHIGAN ST NE FL 10
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-267-7900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 538 BOND AVE NORTHWEST APT 608
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-585-0493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | 4351055276
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------