Provider Demographics
NPI:1730123183
Name:FRIESEN, GARY MERLE (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MERLE
Last Name:FRIESEN
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 1:1414 WEST FAIR AVENUE
Mailing Address - Street 2:SUITE 334
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-225-3870
Mailing Address - Fax:906-225-4861
Practice Address - Street 1:1414 WEST FAIR AVENUE
Practice Address - Street 2:SUITE 334
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-225-3870
Practice Address - Fax:906-225-4861
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069400207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00005099OtherRAILROAD MEDICARE
MI4503044Medicaid
MI1105200068OtherBLUE CROSS BLUE SHIELD
WI34966500Medicaid
WI34966500Medicaid
P00005099OtherRAILROAD MEDICARE
MI4503044Medicaid