Provider Demographics
NPI:1164440277
Name:GRUBER, WALTER J (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:J
Last Name:GRUBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:555 W WACKERLY ST
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4722
Mailing Address - Country:US
Mailing Address - Phone:989-631-8300
Mailing Address - Fax:989-839-8170
Practice Address - Street 1:555 W WACKERLY STREET
Practice Address - Street 2:SUITE 1500
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4712
Practice Address - Country:US
Practice Address - Phone:989-631-8300
Practice Address - Fax:989-839-8170
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIWG038289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIWG038289OtherBCR LICENSE NUMBER
MI2096083Medicaid
MI382209777OtherTAX ID NUMBER
MIB47172Medicare ID - Type Unspecified