Provider Demographics
NPI:1508819517
Name:POLIZZI, KERRY (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:POLIZZI
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:245 STATE ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4328
Practice Address - Country:US
Practice Address - Phone:616-685-1800
Practice Address - Fax:616-685-1818
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4181817Medicaid
MI4181782Medicaid
MI4181764Medicaid
MI4877465Medicaid
MI3482137Medicaid
MI4166697Medicaid
MI3482137Medicaid
MI4181817Medicaid
MIP32930056Medicare ID - Type Unspecified
MI4166697Medicaid