Provider Demographics
NPI:1467415372
Name:BRYAN-BESTEMAN, GAIL K (MD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:K
Last Name:BRYAN-BESTEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 BRETON RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4810
Mailing Address - Country:US
Mailing Address - Phone:616-252-4765
Mailing Address - Fax:616-252-0127
Practice Address - Street 1:2215 44TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-6439
Practice Address - Country:US
Practice Address - Phone:616-252-8300
Practice Address - Fax:616-252-8460
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101078419208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4756998Medicaid
MII42570Medicare UPIN
MIM53750068Medicare ID - Type Unspecified