Provider Demographics
NPI:1609009414
Name:GANCHUA, RANDELL CHUA (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDELL
Middle Name:CHUA
Last Name:GANCHUA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-3139
Mailing Address - Fax:616-391-3044
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:SUITE A721
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-3139
Practice Address - Fax:616-391-3044
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2021-02-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301094295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609009414Medicaid
MI1609009414Medicaid