Provider Demographics
NPI:1679538581
Name:GJERSOE, HEIDI S (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:S
Last Name:GJERSOE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 COOLEY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7430
Mailing Address - Country:US
Mailing Address - Phone:269-349-2266
Mailing Address - Fax:269-349-0792
Practice Address - Street 1:3304 COOLEY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7430
Practice Address - Country:US
Practice Address - Phone:269-349-2266
Practice Address - Fax:269-349-0792
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHG060600207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417961137OtherBCBSM - BRONSON
MI4319176OtherAETNA
MI0M92920001OtherMEDICARE
MI1679538581OtherNPI
MI1679538581Medicaid
MI100987OtherGREAT LAKES HEALTH PLAN
MI1851569958OtherNPI 04/25/2008 AND AFTER
MIHG060600OtherBLUE CROSS BLUE SHIELD
MI0P56360004OtherMEDICARE 04/25/2008 AND AFTER
MI100C910690OtherBCBSM
MI383309299137OtherCARESOURCE MEDICAID
MI100C914640OtherBCBS 04/25/2008 AND AFTER
MI104171768Medicaid
MI1679538581OtherNPI
MI1417961137OtherBCBSM - BRONSON
MI100987OtherGREAT LAKES HEALTH PLAN
MIE18264Medicare UPIN