Provider Demographics
NPI:1710914650
Name:POEHL, ROBERT (PA C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:POEHL
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:230 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327-9006
Practice Address - Country:US
Practice Address - Phone:231-834-5995
Practice Address - Fax:231-834-0248
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S16012Medicare UPIN
N81620004Medicare ID - Type Unspecified