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NPI Code Detail

MEDICARE: MOLLY P CRISSMAN MD

MEDICARE: MOLLY P CRISSMAN 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
1207Q00000XFamily Medicine Physician4301068764MI

General Provider Information

NPI Number : 1902808165
Entity Type Code : Individual
Provider Name (Legal Business Name) : MOLLY P CRISSMAN MD
Provider Business Mailing Address
First Line : 100 MICHIGAN ST NE
Second Line : MC845
City : GRAND RAPIDS
State : MI
Zip : 49503-2560
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 15100 WHITTAKER WAY
Second Line :
City : GRAND HAVEN
State : MI
Zip : 49417-8696
Country : US
Telephone Number : 616-935-6320
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/01/2005
Last Update Date : 09/02/2025

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