Provider Demographics
NPI:1821102013
Name:FREEBURGER, LARA A (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:A
Last Name:FREEBURGER
Suffix:
Gender:F
Credentials:MD
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
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:616-391-2160
Mailing Address - Fax:616-391-2683
Practice Address - Street 1:330 BARCLAY AVE NE
Practice Address - Street 2:SUITE 304
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2556
Practice Address - Country:US
Practice Address - Phone:616-391-2160
Practice Address - Fax:616-391-2683
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066218207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1821102013Medicaid
MI4132151Medicaid
MI0M92649Medicare PIN
MI0D16228-032Medicare PIN
MIM92640Medicare UPIN