NPIMap

Organization Active NPI

Address Healthcare of Michigan PLLC

Doing business as Address Healthcare

  • Internal Medicine Physician
  • Grand Rapids, MI
National Provider Identifier
1043075294
Registry record updated May 5, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
ADDRESS HEALTHCARE OF MICHIGAN PLLC
Doing business as
Address Healthcare
Address Healthcare of Michigan
Practice address
600 Monroe Avenue NW
Ste 104
Grand Rapids, MI 49503-1470
Phone
(616) 366-4234
Fax
(855) 548-4481
NPI assigned
Feb 16, 2024
Last updated
May 5, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 5, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jeffrey L Wacksman
Title
Authorized Official
Phone
(616) 366-4234

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X Primary
Hospice and Palliative Medicine (Internal Medicine) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RH0002X
Geriatric Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0805X
Foot & Ankle Surgery PodiatristGroup: 193200000X MULTI-SPECIALTY GROUP 213ES0103X
Adult Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LA2200X

Addresses

Primary practice location

600 Monroe Avenue NW
Ste 104
Grand Rapids, MI 49503-1470

Mailing address

3940 Peninsular Drive SE
Ste 230
Grand Rapids, MI 49546-2442
Phone (616) 366-4234

Other names 2

  • Address Healthcare Doing business as
  • Address Healthcare of Michigan Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240611000362 MI Part B Supplier - Clinic/Group Practice 5395287924 Receives reassigned benefits from 4 practitioners
Practice locations: Grand Rapids, MI

National Provider Directory

National Provider Directory

Locations

6804 Cecelia Dr
New Prt Rchy, FL 34653
Phone (727) 232-0644

3940 Peninsular Dr SE
Grand Rapids, MI 49546

3940 Peninsular Dr SE
Ste 203
Grand Rapids, MI 49546
Phone (616) 320-1066

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1708041600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746403200000",
    "number": "1043075294",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3940 PENINSULAR DRIVE SE",
            "address_2": "STE 230",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495462442",
            "telephone_number": "616-366-4234",
            "fax_number": "855-548-4481"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 MONROE AVENUE NW",
            "address_2": "STE 104",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495031470",
            "telephone_number": "616-366-4234",
            "fax_number": "855-548-4481"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADDRESS HEALTHCARE OF MICHIGAN PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-02-16",
        "last_updated": "2025-05-05",
        "certification_date": "2025-04-18",
        "status": "A",
        "authorized_official_last_name": "WACKSMAN",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "616-366-4234"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207RH0002X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Hospice and Palliative Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0805X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "213ES0103X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Adult Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Address Healthcare",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Address Healthcare",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Address Healthcare of Michigan",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 5, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.