Provider Demographics
NPI:1295847739
Name:BLEIL, GORDON R (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:R
Last Name:BLEIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:955 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9701
Mailing Address - Country:US
Mailing Address - Phone:269-639-2910
Mailing Address - Fax:269-639-2919
Practice Address - Street 1:955 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9701
Practice Address - Country:US
Practice Address - Phone:269-639-2910
Practice Address - Fax:269-639-2919
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI056047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2937733Medicaid
MI080064237OtherRR MEDICARE
MI0131167OtherPHP/IBA
MIP77691OtherBCN
MI5976083OtherAETNA
MI080H06004OtherBCBSM
MIF59284Medicare UPIN
MI2937733Medicaid