Provider Demographics
NPI:1124011531
Name:BACKUS-WALZER, MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BACKUS-WALZER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BACKUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-2967
Mailing Address - Fax:616-391-2683
Practice Address - Street 1:100 MICHIGAN ST NE # MC027
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:616-391-2160
Practice Address - Fax:616-391-2683
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47016207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34549100Medicaid
WI32666500Medicaid
WI32666500Medicaid
I15463Medicare UPIN
11940006Medicare ID - Type UnspecifiedMILWAUKEE OFFICE