Provider Demographics
NPI:1780682252
Name:VAN WIEREN, GERALD E (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:E
Last Name:VAN WIEREN
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 1:71 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-9701
Mailing Address - Country:US
Mailing Address - Phone:231-834-5676
Mailing Address - Fax:231-834-7211
Practice Address - Street 1:71 S FRONT ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327-9701
Practice Address - Country:US
Practice Address - Phone:231-834-5676
Practice Address - Fax:231-834-7211
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI042527207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2924566Medicaid
MI2924566Medicaid
MI0620012Medicare ID - Type UnspecifiedMEDICARE