Provider Demographics
NPI:1619147493
Name:JOANNE MARIE GRZESZAK DO PC
Entity Type:Organization
Organization Name:JOANNE MARIE GRZESZAK DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRZESZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-452-8923
Mailing Address - Street 1:4310 LEONARD ST NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:806 ALGER ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3803
Practice Address - Country:US
Practice Address - Phone:616-452-8923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI00714208D00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2812013Medicaid
MI54100135OtherBCBS
0154100134OtherBCBSM
MI54100135OtherBCBS
5410013Medicare PIN