Provider Demographics
NPI:1952387573
Name:STALEY, HARRY L (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:L
Last Name:STALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:577 MICHIGAN AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4911
Mailing Address - Country:US
Mailing Address - Phone:616-393-5336
Mailing Address - Fax:616-392-2889
Practice Address - Street 1:577 MICHIGAN AVE
Practice Address - Street 2:STE 203
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4911
Practice Address - Country:US
Practice Address - Phone:616-393-5336
Practice Address - Fax:616-392-2889
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-10-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01024344207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC01678Medicare UPIN
IN067460FMedicare ID - Type Unspecified