Provider Demographics
NPI:1528099884
Name:TAYLOR, BONNIE L (DO)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:L
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-9700
Mailing Address - Fax:616-391-9707
Practice Address - Street 1:4600 BRETON RD SE
Practice Address - Street 2:SUITE 102
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5262
Practice Address - Country:US
Practice Address - Phone:616-391-9970
Practice Address - Fax:616-391-9707
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1528099884Medicaid
MIM33350215Medicare PIN
MID16321053Medicare UPIN
MI0D16299053Medicare PIN
MI1528099884Medicaid