Provider Demographics
NPI:1225099161
Name:DAVIS, FRED NEAL (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:NEAL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4124
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2060 E PARIS AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1154
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301043532208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4532270-10Medicaid
7000027051OtherPRIORITY HEALTH MEDICAID
050044374OtherRAILROAD MEDICARE
11908OtherHEALTH PLAN OF MICHIGAN
MI4552970-10Medicaid
2019450OtherPHYSICIANS HEALTH PLAN
MI550410724OtherBLUE CROSS BLUE SHIELD
7582081OtherCIGNA
4098753OtherAETNA
7000027051OtherPRIORITY HEALTH
MI4532270-10Medicaid
7582081OtherCIGNA