Provider Demographics
NPI:1447299599
Name:VANDERLAAN, RONALD (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:VANDERLAAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 KENMOOR AVE SE STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8622
Mailing Address - Country:US
Mailing Address - Phone:616-900-9911
Mailing Address - Fax:616-900-9862
Practice Address - Street 1:655 KENMOOR AVE SE STE 101
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8622
Practice Address - Country:US
Practice Address - Phone:616-900-9911
Practice Address - Fax:616-900-9862
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046234207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2939555OtherCIGNA
MI1447299599OtherTRICARE
MIMEMBER PTAN P0061774OtherRAILROAD MEDICARE
MI1447299599Medicaid
MI2939555OtherCIGNA