Provider Demographics
NPI:1467464883
Name:SOORYA K. SHARMA,MDPC
Entity Type:Organization
Organization Name:SOORYA K. SHARMA,MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOORYA
Authorized Official - Middle Name:KANT
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-974-9760
Mailing Address - Street 1:1630 FLOWERS MILL DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9694
Mailing Address - Country:US
Mailing Address - Phone:616-361-3613
Mailing Address - Fax:616-361-3613
Practice Address - Street 1:2660 44TH ST SW
Practice Address - Street 2:SUITE 100
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4200
Practice Address - Country:US
Practice Address - Phone:616-974-9760
Practice Address - Fax:616-974-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4467117Medicaid
G72795Medicare UPIN
MI4467117Medicaid