Provider Demographics
NPI:1518950625
Name:NERVIG, RONALD DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DEAN
Last Name:NERVIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2259
Mailing Address - Country:US
Mailing Address - Phone:231-941-0230
Mailing Address - Fax:231-941-0230
Practice Address - Street 1:401 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2259
Practice Address - Country:US
Practice Address - Phone:231-941-0230
Practice Address - Fax:231-941-0230
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010308252084P0800X
IA174932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1587603Medicaid
MIB43717Medicare UPIN
MI0280123Medicare ID - Type Unspecified