Provider Demographics
NPI:1316963374
Name:AUTREY, BRET GREGORY (DO)
Entity type:Individual
Prefix:DR
First Name:BRET
Middle Name:GREGORY
Last Name:AUTREY
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 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
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 1:7 ATKINSON DR STE 200
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1917
Practice Address - Country:US
Practice Address - Phone:231-843-3717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014946208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4926720Medicaid
MII56346Medicare UPIN
MIP34090001Medicare PIN