Basic Information
| Provider Information | |||||||||
| NPI: | 1023071727 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORNOELJE | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | MEDICAL ADMINISTRATION | ||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162523243 | ||||||||
| FaxNumber: | 6162520260 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 CASCADE RD SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495468328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162521500 | ||||||||
| FaxNumber: | 6162521599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101012620 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 2081S0010X | 5101012620 | MI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 207QS0010X | 5101012620 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.