Individual
EDWIN T KORNOELJE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
4300 CASCADE RD SE, GRAND RAPIDS, MI 49546-8328
(616) 252-1500
(616) 252-1599
Mailing address
5900 BYRON CENTER AVE SW, MEDICAL ADMINISTRATION, WYOMING, MI 49519-9606
(616) 252-3243
(616) 252-0260
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
5101012620
MI
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
5101012620
MI
2081S0010X
Sports Medicine (Physical Medicine & Rehabilitation) Physician
5101012620
MI
Other
Enumeration date
04/11/2006
Last updated
12/05/2017
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