1679538581 NPI number — HEIDI S GJERSOE M.D.

Table of content: HEIDI S GJERSOE M.D. (NPI 1679538581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679538581 NPI number — HEIDI S GJERSOE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GJERSOE
Provider First Name:
HEIDI
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1679538581
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3304 COOLEY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49024-7430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-349-2266
Provider Business Mailing Address Fax Number:
269-349-0792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3304 COOLEY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-7430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-349-2266
Provider Business Practice Location Address Fax Number:
269-349-0792
Provider Enumeration Date:
04/20/2006

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: 207RG0100X , with the licence number:  HG060600 , 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: 1417961137 . This is a "BCBSM - BRONSON" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4319176 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0M92920001 . This is a "MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1679538581 . This is a "NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1679538581 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100987 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1851569958 . This is a "NPI 04/25/2008 AND AFTER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: HG060600 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P56360004 . This is a "MEDICARE 04/25/2008 AND AFTER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 100C910690 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383309299137 . This is a "CARESOURCE MEDICAID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 100C914640 . This is a "BCBS 04/25/2008 AND AFTER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104171768 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com