Provider Demographics
NPI:1619032000
Name:TANDY L. CHAMPION, D.O., P.C.
Entity Type:Organization
Organization Name:TANDY L. CHAMPION, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-249-1850
Mailing Address - Street 1:4166 56TH ST., SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2371
Mailing Address - Country:US
Mailing Address - Phone:616-249-1850
Mailing Address - Fax:616-532-8657
Practice Address - Street 1:4166 56TH ST., SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2371
Practice Address - Country:US
Practice Address - Phone:616-249-1850
Practice Address - Fax:616-532-8657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011944207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG81001Medicare UPIN
MIOM65980Medicare ID - Type Unspecified