Provider Demographics
NPI:1417995408
Name:HAZLE, GREGORY L (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:HAZLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3242
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:1787 GRAND RIDGE CT. NE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-774-8131
Practice Address - Fax:616-774-8204
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301057607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900000696OtherPRIORITY HEALTH
MI080D17690OtherBLUE SHIELD
MI4558584OtherAETNA
MI2957048Medicaid
MI4558584OtherAETNA
MI080D17690OtherBLUE SHIELD