Provider Demographics
NPI:1972511400
Name:BALIVET, WENDY SUE (MD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:BALIVET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:SUE
Other - Last Name:UTLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 228
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:10047 CROSSROAD CT SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316
Practice Address - Country:US
Practice Address - Phone:616-685-8850
Practice Address - Fax:616-891-9494
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4679253Medicaid
MI4679253Medicaid
T23040Medicare UPIN
MIMI3233151Medicare PIN