Provider Demographics
NPI:1629090907
Name:PRYOR, TODD A (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:PRYOR
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:PO BOX 3567
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-3567
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:616-285-0846
Practice Address - Street 1:418 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-9806
Practice Address - Country:US
Practice Address - Phone:989-352-7211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009393207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00389049OtherRR MCR
MI114517587Medicaid
MI0F71000OtherBCBSM
MI7000A410180OtherBCBS
P00389049OtherRR MCR
MIN70380007Medicare ID - Type Unspecified
MI0F76001Medicare PIN
MI7000A410180OtherBCBS
MIE96010066Medicare PIN