Provider Demographics
NPI:1114970126
Name:WITHERELL, GERALD SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:SCOTT
Last Name:WITHERELL
Suffix:
Gender:M
Credentials:MD
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 776974
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6974
Mailing Address - Country:US
Mailing Address - Phone:231-672-2119
Mailing Address - Fax:
Practice Address - Street 1:2155 E PARIS AVE SE STE 220
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6195
Practice Address - Country:US
Practice Address - Phone:616-685-3100
Practice Address - Fax:616-685-3111
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070459207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4218917Medicaid
MI4218935Medicaid
MI4591682Medicaid
MI4218819Medicaid
MI4218846Medicaid
MI4218837Medicaid
MI4218855Medicaid
MI4876833Medicaid
MI4218891Medicaid
MI4218864Medicaid
MI4591655Medicaid
MI4218891Medicaid
MI4218935Medicaid
MI4591682Medicaid