Provider Demographics
NPI:1275589863
Name:TAY, EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:TAY
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-6922
Practice Address - Fax:616-685-5101
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076395207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4518735Medicaid
MI4518753Medicaid
MI4876898Medicaid
MI4876898Medicaid
MI4518735Medicaid
MIH89094Medicare UPIN
MIM69390207Medicare ID - Type Unspecified
MIP32930016Medicare ID - Type Unspecified