Provider Demographics
NPI:1457302184
Name:DAUM, LAURIE J (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:DAUM
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:245 STATE ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4348
Practice Address - Country:US
Practice Address - Phone:616-685-8500
Practice Address - Fax:616-685-8075
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4382109Medicaid
MI4380884Medicaid
MI4878471Medicaid
MI3211260Medicaid
MI4349561Medicaid
MI4349570Medicaid
MI4202560Medicaid
MI4349580Medicaid
MI3415582Medicaid
MI4382109Medicaid
MIP32930154Medicare ID - Type Unspecified
MI4878471Medicaid
MI3415582Medicaid