Provider Demographics
NPI:1851340012
Name:MESSENGER, GREGORY GLENN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:GLENN
Last Name:MESSENGER
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 1:1515 LAKE LANSING RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3753
Mailing Address - Country:US
Mailing Address - Phone:517-487-0128
Mailing Address - Fax:517-487-2639
Practice Address - Street 1:1515 LAKE LANSING RD
Practice Address - Street 2:SUITE A
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3753
Practice Address - Country:US
Practice Address - Phone:517-487-0128
Practice Address - Fax:517-487-2639
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGM044698207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIGM044698OtherSTATE LICENSE
MI1622220Medicaid
MI03 000539OtherPHP OF MICHIGAN
MI03 000539OtherPHP OF MICHIGAN
MIAM1395614OtherDEA
MIC36066002Medicare ID - Type Unspecified