Provider Demographics
NPI:1235152158
Name:GERONDALE, NORBERT PAUL (MD)
Entity Type:Individual
Prefix:
First Name:NORBERT
Middle Name:PAUL
Last Name:GERONDALE
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 1:5136 W MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-9638
Mailing Address - Country:US
Mailing Address - Phone:231-766-5965
Mailing Address - Fax:
Practice Address - Street 1:17210 VAN WAGONER RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-604-6040
Practice Address - Fax:616-604-6046
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301405952207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1107010721OtherBLUE CROSS BLUE SHEILD
MIF24336Medicare UPIN
MIP11580001Medicare ID - Type UnspecifiedGROUP PROVIDER ID