Provider Demographics
NPI:1134340003
Name:KRISSOFF, MADELON K (MD)
Entity type:Individual
Prefix:DR
First Name:MADELON
Middle Name:K
Last Name:KRISSOFF
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:515 LAKESIDE DRIVE SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:616-774-2588
Mailing Address - Fax:616-774-6839
Practice Address - Street 1:233 E. FULTON
Practice Address - Street 2:SUITE #102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-744-2588
Practice Address - Fax:616-744-6839
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2014-08-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301406025207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4116499Medicaid
MI4116499Medicaid
E77501Medicare UPIN