Provider Demographics
NPI:1992701452
Name:FITZGERALD, GREGORY BERNARD (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:BERNARD
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S ADAMS RD
Mailing Address - Street 2:STE 200
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6863
Mailing Address - Country:US
Mailing Address - Phone:248-646-3733
Mailing Address - Fax:248-642-2566
Practice Address - Street 1:600 S ADAMS RD
Practice Address - Street 2:STE 200
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6863
Practice Address - Country:US
Practice Address - Phone:248-646-3733
Practice Address - Fax:248-642-2566
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070156207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7532354OtherAETNA
MIH54083OtherPPOM UPIN
MI14377OtherM-CARE
MIG5031FOtherBLUE CARE NETWORK GROUP #
MI180F321870OtherBLUE CROSS GROUP
H50483OtherHAP
MI135378OtherCARE CHOICES ID #
MIH50483OtherHAP UPIN
MI7532354OtherAETNA
MIH50483OtherHAP UPIN
MI0N79160Medicare ID - Type UnspecifiedMEDICARE GROUP
MIP00062524Medicare PIN