Provider Demographics
NPI:1689665465
Name:POLIDORI, GREGG (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:
Last Name:POLIDORI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:STE 202
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6770
Mailing Address - Country:US
Mailing Address - Phone:248-551-0900
Mailing Address - Fax:248-551-0905
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:STE 202
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-0900
Practice Address - Fax:248-551-0905
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301407183207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2836230Medicaid
0F371439101Medicare ID - Type Unspecified
MI2836230Medicaid