Provider Demographics
NPI:1194771972
Name:VANWIENEN, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:VANWIENEN
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:7780 20TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8524
Practice Address - Country:US
Practice Address - Phone:616-685-8700
Practice Address - Fax:616-457-5567
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3416300Medicaid
MI4155666Medicaid
MI4876870Medicaid
MI3358029Medicaid
MI4155666Medicaid
MIM69390070Medicare ID - Type Unspecified
MI3358029Medicaid
MIP32930152Medicare ID - Type Unspecified