Provider Demographics
NPI:1114979929
Name:KLIPHUIS, SALLY (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:KLIPHUIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:933 3 MILE RD NW
Practice Address - Street 2:SUITE 210
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49544-1673
Practice Address - Country:US
Practice Address - Phone:616-685-8150
Practice Address - Fax:616-785-0238
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3415690Medicaid
MI3192431Medicaid
MI4186107Medicaid
MI4186054Medicaid
MI4168136Medicaid
MI4186054Medicaid
MI4168136Medicaid
MI3192431Medicaid