Provider Demographics
NPI:1104833946
Name:HARE, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:HARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 406153
Mailing Address - Street 2:
Mailing Address - City:ALANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1876
Mailing Address - Country:US
Mailing Address - Phone:989-799-1611
Mailing Address - Fax:989-799-1622
Practice Address - Street 1:3175 CHRISTY WAY
Practice Address - Street 2:STE 4
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603
Practice Address - Country:US
Practice Address - Phone:989-799-1611
Practice Address - Fax:989-799-1622
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000048231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
540G30252OtherBLUE CROSS OF MICHIGAN
GH083147OtherBLUE CROSS OF MICHIGAN
GH083147OtherBLUE CARE NETWORK
MI1104833946Medicaid
540G30252OtherBLUE CROSS OF MICHIGAN