Provider Demographics
NPI:1619913472
Name:STEFANEK, GREGG J (DO)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:J
Last Name:STEFANEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1447 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4727
Mailing Address - Country:US
Mailing Address - Phone:989-583-2833
Mailing Address - Fax:989-583-1440
Practice Address - Street 1:1910 PINE AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1298
Practice Address - Country:US
Practice Address - Phone:989-463-3101
Practice Address - Fax:989-463-2824
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301011417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619913472Medicaid
MI2772212Medicaid
MIM74750301Medicare PIN
MI0B96009004Medicare ID - Type Unspecified
MI1619913472Medicaid