Provider Demographics
NPI:1215955752
Name:MERVENNE, GREGORY S (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:MERVENNE
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 MICHIGAN ST NE
Practice Address - Street 2:SUITE 4400
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2562
Practice Address - Country:US
Practice Address - Phone:616-391-9945
Practice Address - Fax:616-486-6346
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060010207PE0004X, 207RH0002X, 207PH0002X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI930082289OtherRAILROAD MEDICARE
MIG96015Medicare UPIN
MID16094058Medicare PIN
MIP41120006Medicare PIN