Provider Demographics
NPI:1386030930
Name:DEGRYSE, MICHAEL ERIC (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ERIC
Last Name:DEGRYSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9730 BUNTON RD
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:MI
Mailing Address - Zip Code:48191-9625
Mailing Address - Country:US
Mailing Address - Phone:734-732-0056
Mailing Address - Fax:
Practice Address - Street 1:36475 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1971
Practice Address - Country:US
Practice Address - Phone:734-655-4800
Practice Address - Fax:734-655-8430
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101024461207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program