MEDICARE: DR. LARA JEAN BAATENBURG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301109996	MI

General Provider Information

NPI Number	:	1336590843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARA JEAN BAATENBURG MD

Provider Business Mailing Address
First Line	:	950 36TH ST SW
Second Line	:
City	:	WYOMING
State	:	MI
Zip	:	49509-3587
Country	:	US
Telephone Number	:	616-685-3300
Fax Number	:	616-685-3303

Provider Business Practice Location Address
First Line	:	6741 FULTON ST E STE 200
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-9502
Country	:	US
Telephone Number	:	616-290-1650
Fax Number	:	833-973-4117

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2016
Last Update Date	:	02/11/2025

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