Provider Demographics
NPI:1962403709
Name:OVERLY, GEORGE E (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:E
Last Name:OVERLY
Suffix:
Gender:M
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 1:800 E ELLIS RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5622
Mailing Address - Country:US
Mailing Address - Phone:231-798-9840
Mailing Address - Fax:231-798-9740
Practice Address - Street 1:800 E ELLIS RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-5622
Practice Address - Country:US
Practice Address - Phone:231-798-9840
Practice Address - Fax:231-798-9740
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7000006801Medicaid
MIP17470001Medicare ID - Type Unspecified
MA7000006801Medicaid