Provider Demographics
NPI:1700852977
Name:FORNESS, MICHAEL J (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:FORNESS
Suffix:
Gender:M
Credentials:DO
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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:
Mailing Address - Fax:
Practice Address - Street 1:550 MUNSON AVE STE 202
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:616-267-2600
Practice Address - Fax:616-267-2601
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101008877207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4632079Medicaid
MI1558407189OtherGROUP NPI
MI2052800944OtherBCBS
MI4632079Medicaid