Provider Demographics
NPI:1689608838
Name:GEDWILL, MICHAEL A (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GEDWILL
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 1:2222 S LINDEN RD
Mailing Address - Street 2:SUITE R
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-5475
Mailing Address - Country:US
Mailing Address - Phone:810-733-0450
Mailing Address - Fax:810-733-2830
Practice Address - Street 1:2222 S LINDEN RD
Practice Address - Street 2:SUITE R
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5475
Practice Address - Country:US
Practice Address - Phone:810-733-0450
Practice Address - Fax:810-733-2830
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0126912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4955839Medicaid
H24638Medicare UPIN