Active NPI
Rolland Dean Mambourg, MD
- Family Medicine Physician
- Grand Rapids, MI
National Provider Identifier
1417294620
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 4301039783
- Practice address
- 200 Jefferson Ave SE
Medical Staff Office
Grand Rapids, MI 49503-4502 - Phone
- (616) 685-6612
- Fax
- (616) 685-8921
- NPI assigned
- Jan 8, 2013
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 4301039783 | MI | Primary |
Addresses
Primary practice location
200 Jefferson Ave SE
Medical Staff Office
Grand Rapids, MI 49503-4502
Mailing address
200 Jefferson Ave SE
Medical Staff Office
Grand Rapids, MI 49503-4502
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4301039783 | MI | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1357603200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1357603200000",
"number": "1417294620",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "200 JEFFERSON AVE SE",
"address_2": "MEDICAL STAFF OFFICE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495034502"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "200 JEFFERSON AVE SE",
"address_2": "MEDICAL STAFF OFFICE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495034502",
"telephone_number": "616-685-6612",
"fax_number": "616-685-8921"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MAMBOURG",
"first_name": "ROLLAND",
"middle_name": "DEAN",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2013-01-08",
"last_updated": "2013-01-08",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MI",
"license": "4301039783",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}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 Jan 8, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.