Provider Demographics
NPI:1417139692
Name:ALT, NAN BETH (MD)
Entity Type:Individual
Prefix:
First Name:NAN
Middle Name:BETH
Last Name:ALT
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 1:151 44TH STREET, S.W.
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418
Mailing Address - Country:US
Mailing Address - Phone:616-457-1889
Mailing Address - Fax:616-457-1891
Practice Address - Street 1:151 44TH STREET, S.W.
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:616-457-1889
Practice Address - Fax:616-457-1891
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010456692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB46269Medicare UPIN
MIN84110001Medicare PIN
MI3085001Medicare PIN