Individual
JOHN STEPHEN EBROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
200 JEFFERSON AVE SE, GRAND RAPIDS, MI 49503
(616) 364-6700
(616) 364-4960
Mailing address
PO BOX 77000, DEPT #77339, DETROIT, MI 48277-0339
(616) 364-6700
(616) 364-4960
Taxonomy
Speciality
Code
Description
License number
State
207ZP0105X
Clinical Pathology/Laboratory Medicine Physician
Primary
4301044412
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4525177100
—
MI
01
—
P00009267
RR MEDICARE
MI
Enumeration date
08/12/2006
Last updated
08/20/2007
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