Provider Demographics
NPI:1093991457
Name:FAMILY PHYSICIANS-DR PHILLIP J GACA PC
Entity Type:Organization
Organization Name:FAMILY PHYSICIANS-DR PHILLIP J GACA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-365-7614
Mailing Address - Street 1:6265 WEST RIVER DR NE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-9078
Mailing Address - Country:US
Mailing Address - Phone:616-365-7614
Mailing Address - Fax:
Practice Address - Street 1:6265 WEST RIVER DR NE
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MI
Practice Address - Zip Code:49306-9078
Practice Address - Country:US
Practice Address - Phone:616-365-7614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3018321Medicaid
MI3018321Medicaid