Provider Demographics
NPI:1477550689
Name:VANDERLUGT, GERRIT (DO)
Entity Type:Individual
Prefix:
First Name:GERRIT
Middle Name:
Last Name:VANDERLUGT
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 1:224 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MI
Mailing Address - Zip Code:48880-1523
Mailing Address - Country:US
Mailing Address - Phone:989-681-3524
Mailing Address - Fax:989-681-2683
Practice Address - Street 1:224 N MILL ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-1523
Practice Address - Country:US
Practice Address - Phone:989-681-3524
Practice Address - Fax:989-681-2683
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGV007721208D00000X
MI5101007721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1020574OtherMCLAREN HEALTH PLAN
MI0852914964OtherBCBSM
MI200000005905OtherPHP COMMERCIAL
MI114893389Medicaid
MI0983154OtherHEALTHPLUS COMMERCIAL
MI114893389Medicaid
MI200000005905OtherPHP COMMERCIAL
MIM17400030Medicare PIN
MI0852914964OtherBCBSM