Provider Demographics
NPI:1033407689
Name:STEPHANOFF, NICHOLAS ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:STEPHANOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
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:
Mailing Address - Fax:
Practice Address - Street 1:426 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5609
Practice Address - Country:US
Practice Address - Phone:616-267-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0512207Q00000X
MI4301099542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79503322Medicaid
NM385270YNGGMedicare Oscar/Certification