Provider Demographics
NPI:1699707380
Name:SPRINGBERG, TAMARA (PAC)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:SPRINGBERG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:SPRINGBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:4055 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2149
Practice Address - Country:US
Practice Address - Phone:616-252-5760
Practice Address - Fax:616-252-3608
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16078458Medicaid
MI0N38850076Medicare PIN
MI0M31990024Medicare PIN