Provider Demographics
NPI:1558314765
Name:CHAMPION, LAURA DEANN (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:DEANN
Last Name:CHAMPION
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 1:3195 KNIGHT WAY SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4409
Mailing Address - Country:US
Mailing Address - Phone:616-526-6678
Mailing Address - Fax:616-526-6548
Practice Address - Street 1:3195 KNIGHT WAY SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4406
Practice Address - Country:US
Practice Address - Phone:616-526-6187
Practice Address - Fax:616-469-1398
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4166857Medicaid
MI4161028Medicaid
MI4166848Medicaid
MI1609147339OtherCALVIN COLLEGE HEALTH SERVICES GROUP NPI
MI4202588Medicaid
MI4876913Medicaid
MIM02830068Medicare ID - Type Unspecified
MI4202588Medicaid
MIM69390117Medicare ID - Type Unspecified