Provider Demographics
NPI:1720073794
Name:COLLER, GARY HAYES (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:HAYES
Last Name:COLLER
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 1:300 S STATE ST
Mailing Address - Street 2:#5
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1676
Mailing Address - Country:US
Mailing Address - Phone:616-772-0700
Mailing Address - Fax:616-772-0777
Practice Address - Street 1:300 S STATE ST
Practice Address - Street 2:#5
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1676
Practice Address - Country:US
Practice Address - Phone:616-772-0700
Practice Address - Fax:616-772-0777
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007512208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5612614Medicare ID - Type Unspecified
E25893Medicare UPIN