Provider Demographics
NPI:1275795239
Name:PROVATAS, TAMMY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:LYNN
Last Name:PROVATAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1699 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-3400
Mailing Address - Country:US
Mailing Address - Phone:231-740-3750
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE # MC-49
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:616-391-8879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092916207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine