1194720284 NPI number — GREGORY J CERILLI MD

Table of content: GREGORY J CERILLI MD (NPI 1194720284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194720284 NPI number — GREGORY J CERILLI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CERILLI
Provider First Name:
GREGORY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194720284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 0446
Provider Second Line Business Mailing Address:
24 FRANK LLOYD WRIGHT DR. LOBBY J
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-291-5150
Provider Business Mailing Address Fax Number:
419-479-6173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5301 E. HURON RIVER DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-712-7017
Provider Business Practice Location Address Fax Number:
734-712-2844
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  35069105 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: 4301104239 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0102X , with the licence number: 4301104239 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7077263 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04572 . This is a "PARAMOUNT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1194720284 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00462488 . This is a "RRMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000522576 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2482942 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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