Provider Demographics
NPI:1780648170
Name:SACKETT, GARY N (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:N
Last Name:SACKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:4200 DIVISION AVE N
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9546
Practice Address - Country:US
Practice Address - Phone:616-252-1600
Practice Address - Fax:616-252-1666
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101080099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII35569Medicare UPIN
MIM53750062Medicare PIN
MI08-0-70-1089-2OtherBCBS PIN
MI170648170Medicaid