Provider Demographics
NPI:1093702169
Name:GREGORY, DENNIS C (PAC)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:C
Last Name:GREGORY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:616-464-6170
Practice Address - Street 1:1111 LEFFINGWELL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6406
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:616-464-6170
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003804363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00128331OtherRR MEDICARE
MI0P18140OtherGROUP MEDICARE PTAN
MIP18140006OtherMEDICARE PTAN
MI0P18140OtherGROUP MEDICARE PTAN
MIP18140006OtherMEDICARE PTAN