Provider Demographics
NPI:1588645139
Name:TRIESENBERG, STEVEN NEAL (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:NEAL
Last Name:TRIESENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 JEFFERSON AVE SE STE 115
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4597
Practice Address - Country:US
Practice Address - Phone:616-685-3100
Practice Address - Fax:616-685-3111
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407220207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4900278Medicaid
MI110D148350 / 0415028OtherBCBSM
MIF31027Medicare UPIN
MI4900278Medicaid