Provider Demographics
NPI:1598775850
Name:LAMBOURNE, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LAMBOURNE
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:PO BOX 384
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-0384
Mailing Address - Country:US
Mailing Address - Phone:231-775-6076
Mailing Address - Fax:231-775-0027
Practice Address - Street 1:1866 S MOREY RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-9190
Practice Address - Country:US
Practice Address - Phone:231-775-4841
Practice Address - Fax:231-839-7222
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036909207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1105708412OtherBLUE CROSS BLUE SHIELD
MI2092861-10Medicaid
B46488Medicare UPIN
1105708412OtherBLUE CROSS BLUE SHIELD