Provider Demographics
NPI:1275583304
Name:VERSEMAN, STUART RAY (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:RAY
Last Name:VERSEMAN
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 1:1717 SHAFFER ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1647
Mailing Address - Country:US
Mailing Address - Phone:269-343-9113
Mailing Address - Fax:269-343-0510
Practice Address - Street 1:1717 SHAFFER ST
Practice Address - Street 2:SUITE 108
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1647
Practice Address - Country:US
Practice Address - Phone:269-343-9113
Practice Address - Fax:269-343-0510
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086883208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0203911911OtherBCBSM
MI4825244Medicaid
MIC46087Medicare UPIN
MI4825244Medicaid
0P24850Medicare ID - Type Unspecified