1013041532 NPI number — RANDOLPH JOSEPH GRIERSON III D.O.

Table of content: RANDOLPH JOSEPH GRIERSON III D.O. (NPI 1013041532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013041532 NPI number — RANDOLPH JOSEPH GRIERSON III D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIERSON
Provider First Name:
RANDOLPH
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013041532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MICHIGAN ST NE # MC845
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-2560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-486-6790
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 ATKINSON DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUDINGTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49431-1953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-843-2664
Provider Business Practice Location Address Fax Number:
231-845-6873
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  5101015592 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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