Provider Demographics
NPI:1902896111
Name:GAUTHIER, MARIE G (MD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:G
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MULHOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-7644
Mailing Address - Country:US
Mailing Address - Phone:989-892-3541
Mailing Address - Fax:989-892-5336
Practice Address - Street 1:515 MULHOLLAND ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7644
Practice Address - Country:US
Practice Address - Phone:989-892-3541
Practice Address - Fax:989-892-5336
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301044702207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1405068Medicaid
MI0987594OtherHEALTHPLUS PROVIDER ID
MI0400900151OtherBCBSM PIN
MIB43277Medicare UPIN
MI0987594OtherHEALTHPLUS PROVIDER ID