Basic Information
| Provider Information | |||||||||
| NPI: | 1457302184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAUM | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | 6166851850 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858500 | ||||||||
| FaxNumber: | 6166858075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301053702 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4382109 | 05 | MI | MEDICAID | 4380884 | 05 | MI | MEDICAID | 4878471 | 05 | MI | MEDICAID | 3211260 | 05 | MI | MEDICAID | 4349561 | 05 | MI | MEDICAID | 4349570 | 05 | MI | MEDICAID | 4202560 | 05 | MI | MEDICAID | 4349580 | 05 | MI | MEDICAID | 3415582 | 05 | MI | MEDICAID |