Provider Demographics
NPI:1033177753
Name:FELLER, GRETCHEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:M
Last Name:FELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 STEWART RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4393
Mailing Address - Country:US
Mailing Address - Phone:734-384-1660
Mailing Address - Fax:734-457-9030
Practice Address - Street 1:331 STEWART RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4393
Practice Address - Country:US
Practice Address - Phone:734-384-1660
Practice Address - Fax:734-457-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34044174400000X
MIGF089113208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI05810871OtherBLUE CROSS BLUE SHIELD
MI4964720Medicaid
BF6699536OtherDEA CERTIFICATE
MIP40850001Medicare PIN
MI4964720Medicaid
MI0P40850Medicare PIN