Provider Demographics
NPI:1104861087
Name:GOLEN, GREGORY J
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:GOLEN
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 1:1301 W LONG LAKE RD
Mailing Address - Street 2:SUITE 237
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-6328
Mailing Address - Country:US
Mailing Address - Phone:800-543-1963
Mailing Address - Fax:
Practice Address - Street 1:1301 W LONG LAKE RD
Practice Address - Street 2:SUITE 237
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-6328
Practice Address - Country:US
Practice Address - Phone:800-543-1963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704127077367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4520869Medicaid
MIP00047520Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MIP52260003Medicare PIN