Provider Demographics
NPI:1316054125
Name:AVEDISIAN, RALPH (DO)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:AVEDISIAN
Suffix:
Gender:M
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:
Mailing Address - Fax:
Practice Address - Street 1:7 N ATKINSON DR
Practice Address - Street 2:SUITE 111
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1953
Practice Address - Country:US
Practice Address - Phone:231-843-3487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008322207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2647582Medicaid
MI0E036013Medicare ID - Type Unspecified
MIC96832Medicare UPIN