Provider Demographics
NPI:1336763275
Name:VANHAM, ELEXUS-EMBER ALECZANDRIA (DO)
Entity Type:Individual
Prefix:DR
First Name:ELEXUS-EMBER
Middle Name:ALECZANDRIA
Last Name:VANHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ELEXUS-EMBER
Other - Middle Name:
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4100 EMBASSY DR SE STE 400
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2416
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:
Practice Address - Street 1:1 ATKINSON DR
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1906
Practice Address - Country:US
Practice Address - Phone:606-218-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-06
Last Update Date:2023-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315225350207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336763275Medicaid