Provider Demographics
NPI:1164457917
Name:NORRIS, VICKY LYNN (DO)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:LYNN
Last Name:NORRIS
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 1:100 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:616-391-2778
Mailing Address - Fax:616-486-5076
Practice Address - Street 1:6105 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-9714
Practice Address - Country:US
Practice Address - Phone:616-391-2778
Practice Address - Fax:616-486-5076
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011342207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11284828OtherCAQH PROVIDER ID
MI0156910165OtherBCBSM
MI1164457917Medicaid
MI700C910950OtherBCBSM
MI4606954Medicaid
MI1164457917Medicaid
MI0M43930009Medicare PIN
MI4606954Medicaid
MIM79650049Medicare UPIN
G05601Medicare UPIN
MNC96159051Medicare PIN
MNC96159051Medicare PIN