Provider Demographics
NPI:1033747118
Name:EICKHOLTZ, ALLIE SANDRA (MD)
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:SANDRA
Last Name:EICKHOLTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALLIE
Other - Middle Name:SANDRA
Other - Last Name:DAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE STE A501
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:616-391-6243
Mailing Address - Fax:616-391-8611
Practice Address - Street 1:100 MICHIGAN ST NE STE A501
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-6243
Practice Address - Fax:616-391-8611
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4351046434208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program