Provider Demographics
NPI:1194720284
Name:CERILLI, GREGORY J (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:CERILLI
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:PO BOX 0446
Mailing Address - Street 2:24 FRANK LLOYD WRIGHT DR. LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106
Mailing Address - Country:US
Mailing Address - Phone:419-291-5150
Mailing Address - Fax:419-479-6173
Practice Address - Street 1:5301 E. HURON RIVER DR.
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-7017
Practice Address - Fax:734-712-2844
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069105208600000X
MI43011042392086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
7077263OtherAETNA
04572OtherPARAMOUNT
MI1194720284Medicaid
P00462488OtherRRMC
000000522576OtherANTHEM
OH2482942Medicaid
000000522576OtherANTHEM
7077263OtherAETNA
H32863Medicare UPIN
OHCE4134341Medicare ID - Type Unspecified