Provider Demographics
NPI:1639381460
Name:GULL CROSSING FAMILY PRACTICE, P.C.
Entity Type:Organization
Organization Name:GULL CROSSING FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-385-2784
Mailing Address - Street 1:PO BOX 2588
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2588
Mailing Address - Country:US
Mailing Address - Phone:269-385-2784
Mailing Address - Fax:269-385-2321
Practice Address - Street 1:3048 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2956
Practice Address - Country:US
Practice Address - Phone:269-385-2784
Practice Address - Fax:269-385-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0803927361OtherBLUE CROSS
MIP208900780OtherBLUE CROSS
MI103328861Medicaid
MI0P02300Medicare PIN
MI0803927361OtherBLUE CROSS
MI103328861Medicaid