Provider Demographics
NPI:1043075294
Name:ADDRESS HEALTHCARE OF MICHIGAN PLLC
Entity Type:Organization
Organization Name:ADDRESS HEALTHCARE OF MICHIGAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WACKSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-366-4234
Mailing Address - Street 1:6804 CECELIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653
Mailing Address - Country:US
Mailing Address - Phone:616-366-4234
Mailing Address - Fax:855-548-4481
Practice Address - Street 1:600 MONROE AVENUE NW
Practice Address - Street 2:STE 104
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1470
Practice Address - Country:US
Practice Address - Phone:616-366-4234
Practice Address - Fax:855-548-4481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty