Provider Demographics
NPI:1710074125
Name:GOLLISH, STEVEN HAROLD (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:HAROLD
Last Name:GOLLISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-3404
Mailing Address - Country:US
Mailing Address - Phone:989-240-0221
Mailing Address - Fax:
Practice Address - Street 1:1010 W NORTH DOWN RIVER RD
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-2060
Practice Address - Country:US
Practice Address - Phone:989-348-0880
Practice Address - Fax:989-348-5725
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045866208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1524935Medicaid
P28330002Medicare PIN
MI1524935Medicaid