Provider Demographics
NPI:1003336850
Name:QUINN, CARLY ROSE (DO)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:ROSE
Last Name:QUINN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:ROSE
Other - Last Name:BRUNS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:100 MICHIGAN ST NE # MC-845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-498-6702
Practice Address - Street 1:3185 MACATAWA DR SW STE A
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3184
Practice Address - Country:US
Practice Address - Phone:616-391-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025641207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003336850Medicaid