Basic Information
| Provider Information | |||||||||
| NPI: | 1407817349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUIPER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | LARS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5555 GLENWOOD HILLS PKWY SE STE 2 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169402662 | ||||||||
| FaxNumber: | 6169401965 | ||||||||
| Practice Location | |||||||||
| Address1: | 3770 GLENKERRY CT | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490240700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693292887 | ||||||||
| FaxNumber: | 2693292805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 5101014357 | MI | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 5101014357 | MI | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2030338 | 01 | PHYSICIANS HEALTH PLAN IB | OTHER | 7193668 | 01 | AETNA | OTHER | 247282202 | 01 | UNITED HEALTH CARE | OTHER | 4660402-11 | 05 | MI | MEDICAID | 553910515 | 01 | MI | BCBSM | OTHER | 2282530 | 01 | FIRST HEALTH | OTHER | 34418 | 01 | HEALTH PLAN OF MICHIGAN | OTHER | P00209743 | 01 | RAILROAD MEDICARE | OTHER | 4660396-11 | 05 | MI | MEDICAID | 4630299-11 | 05 | MI | MEDICAID |