Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | 4301098173 | MI |
N | 208000000X | Pediatrician | 4301098173 | MI |
N | 208000000X | Pediatrician | 51391 | CO |
NPI | 1255507596 |
---|---|
Provider Name | Gina South |
First Address | Grand Rapids, MI 49503-1455 |
Second Address | Grand Rapids, MI 49503-1455 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/05/2008 |
Last Update Date | 05/12/2018 |