Provider Demographics
NPI:1598727935
Name:HENRY, ELIZABETH H (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:H
Last Name:HENRY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:791 KENMOOR AVE SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8625
Mailing Address - Country:US
Mailing Address - Phone:616-575-8200
Mailing Address - Fax:616-954-9622
Practice Address - Street 1:791 KENMOOR AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8625
Practice Address - Country:US
Practice Address - Phone:616-575-8200
Practice Address - Fax:616-954-9622
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2015-09-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301070226207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H39328Medicare UPIN
P52990002Medicare PIN
N30080001Medicare PIN