Provider Demographics
NPI:1245201490
Name:BAILEY, GARY W (D O)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:BAILEY
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 BURTON ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4834
Mailing Address - Country:US
Mailing Address - Phone:616-957-2410
Mailing Address - Fax:
Practice Address - Street 1:2525 BURTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-957-2410
Practice Address - Fax:616-957-2411
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007477207Q00000X
MIGB007477207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0154103875OtherBCBSM ID
MI1779765Medicaid
MI1779765Medicaid
MI0154103875OtherBCBSM ID