Provider Demographics
NPI:1932174109
Name:MICHIGAN ORTHOPAEDICS AND SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:MICHIGAN ORTHOPAEDICS AND SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-451-9925
Mailing Address - Street 1:2911 KNAPP ST NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-451-9925
Mailing Address - Fax:616-328-5380
Practice Address - Street 1:2911 KNAPP ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-451-9925
Practice Address - Fax:616-451-9896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6187090001Medicare NSC
MI0N33690Medicare PIN