Provider Demographics
NPI:1679536718
Name:KOELZER, TERESA M (CRNA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:KOELZER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ANN ST NW
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2052
Mailing Address - Country:US
Mailing Address - Phone:616-808-3944
Mailing Address - Fax:616-808-3948
Practice Address - Street 1:1919 BOSTON ST SE
Practice Address - Street 2:METRO HEALTH - HOSPITAL
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4160
Practice Address - Country:US
Practice Address - Phone:616-808-3944
Practice Address - Fax:616-808-3948
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704141580367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM58670004Medicare ID - Type Unspecified
MIP79508Medicare UPIN