Provider Demographics
NPI:1215111885
Name:RAEDY, DOUGLAS JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:RAEDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 GLENKERRY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-0700
Mailing Address - Country:US
Mailing Address - Phone:269-327-7200
Mailing Address - Fax:269-327-9272
Practice Address - Street 1:3850 GLENKERRY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0700
Practice Address - Country:US
Practice Address - Phone:269-327-7200
Practice Address - Fax:269-327-9272
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDR009649207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2745903Medicaid
MI1753900045OtherBLUE CROSS BLUE SHIELDI
MI2745903Medicaid
MI5390045Medicare PIN
MIMI4416001Medicare PIN