Basic Information
| Provider Information | |||||||||
| NPI: | 1679526792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAMBURELLO | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | |||||||||
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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: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | 6166851850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301056427 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3403910 | 05 | MI | MEDICAID | 4278030 | 05 | MI | MEDICAID | 4181675 | 05 | MI | MEDICAID | 4278076 | 05 | MI | MEDICAID | 4269765 | 05 | MI | MEDICAID | 4878892 | 05 | MI | MEDICAID | 4878927 | 05 | MI | MEDICAID | 2994892 | 05 | MI | MEDICAID | 4278049 | 05 | MI | MEDICAID | 4278085 | 05 | MI | MEDICAID | 4748163 | 05 | MI | MEDICAID | 4878936 | 05 | MI | MEDICAID | 3415887 | 05 | MI | MEDICAID | 3436116 | 05 | MI | MEDICAID | 4517086 | 05 | MI | MEDICAID | 4878945 | 05 | MI | MEDICAID |