Provider Demographics
NPI:1093058737
Name:GRAVELIE, GWENDOLYN M (MD)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:M
Last Name:GRAVELIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GWENDOLYN
Other - Middle Name:
Other - Last Name:FITZ-GERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2513 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5325
Mailing Address - Country:US
Mailing Address - Phone:231-935-6080
Mailing Address - Fax:
Practice Address - Street 1:1400 MEDICAL CAMPUS DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7823
Practice Address - Country:US
Practice Address - Phone:231-935-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301109474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program