Provider Demographics
NPI:1215966957
Name:STEBELTON, GARY D (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:STEBELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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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 1:2750 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-8614
Practice Address - Country:US
Practice Address - Phone:616-447-5870
Practice Address - Fax:616-391-7733
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301407210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1004341OtherMCLAREN HEALTH PLAN
MI1102900551OtherBCBSM
MI3414128-10Medicaid
MI0984252OtherHEALTHPLUS COMMERCIAL
MI200000005890OtherPHP COMMERCIAL
MI1004341OtherMCLAREN HEALTH PLAN
MIF04138Medicare UPIN
MI0984252OtherHEALTHPLUS COMMERCIAL