=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710541404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL KENNETH HOFMAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2019
-----------------------------------------------------
Last Update Date | 10/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2093 HEALTH DR SW STE 200
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49519-9691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-459-3158
-----------------------------------------------------
Fax | 616-819-2222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2128 CHESANING DR SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-5311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-581-3606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301510242
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 4301510242
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------