Provider Demographics
NPI:1699714766
Name:LANDIS, GREGORY HALL (DO)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:HALL
Last Name:LANDIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3515 COOLIDGE RD
Mailing Address - Street 2:STE B
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8014
Mailing Address - Country:US
Mailing Address - Phone:517-999-3930
Mailing Address - Fax:517-999-3931
Practice Address - Street 1:3515 COOLIDGE RD
Practice Address - Street 2:STE B
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8014
Practice Address - Country:US
Practice Address - Phone:517-999-3930
Practice Address - Fax:517-999-3931
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI51010094522086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI253055OtherMCLAREN HEALTH PLAN
MI0995992OtherHEALTHPLUS
MI4138612OtherAETNA
MI253055OtherMCLAREN HEALTH ADVANTAGE
MI4155773Medicaid
MI3353301174OtherBCBS/BCN
MI18-00004OtherPHP
MI18-70004OtherPHP FAMILYCARE
MI330005122OtherRAILROAD MEDICARE
MI18-00004OtherPHP
MI0M91500002Medicare ID - Type UnspecifiedMEDICARE