Provider Demographics
NPI:1164443578
Name:CHAMPION, TANDY (DO)
Entity Type:Individual
Prefix:
First Name:TANDY
Middle Name:
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4166 56TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9352
Mailing Address - Country:US
Mailing Address - Phone:616-249-1850
Mailing Address - Fax:616-532-8657
Practice Address - Street 1:4166 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-9352
Practice Address - Country:US
Practice Address - Phone:616-249-1850
Practice Address - Fax:616-532-8657
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011944207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG81001Medicare UPIN
MIOM65980Medicare ID - Type Unspecified