=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881059251
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZA MACDONALD MPA, AT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2015
-----------------------------------------------------
Last Update Date | 12/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CAMPUS DR KHS 4418
-----------------------------------------------------
City | ALLENDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49401-9401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-331-8877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11247 RED HAWK LN
-----------------------------------------------------
City | ALLENDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49401-8071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-304-1686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------