Provider Demographics
NPI:1164609442
Name:GARY L WEASE MD PC
Entity Type:Organization
Organization Name:GARY L WEASE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:WEASE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-733-9760
Mailing Address - Street 1:PO BOX 320309
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-0006
Mailing Address - Country:US
Mailing Address - Phone:810-733-9760
Mailing Address - Fax:
Practice Address - Street 1:G3286 BEECHER RD
Practice Address - Street 2:SUITE E
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3614
Practice Address - Country:US
Practice Address - Phone:810-733-9760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0980253OtherHEALTHPLUS
MIC5296OtherMCARE PROVIDER #
MIP00096336OtherRAILROAD MEDICARE PROV #
MI1007216OtherMCLAREN HEALTH PLAN
MI103347535Medicaid
MI139110OtherGREAT LAKES HEALTH PLAN
MI0202510241OtherBCBSM PROVIDER #
MIF97542Medicare UPIN
MI1007216OtherMCLAREN HEALTH PLAN