Provider Demographics
NPI:1982643466
Name:SAMUELSON, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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:
Mailing Address - Fax:
Practice Address - Street 1:6105 WILSON AVE SW
Practice Address - Street 2:SUITE 202
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-9714
Practice Address - Country:US
Practice Address - Phone:616-486-5299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053065207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16150010Medicare ID - Type Unspecified
MI0M744260228Medicare PIN
E87897Medicare UPIN