Provider Demographics
NPI:1861450660
Name:VITELLO, BLASE (MD)
Entity Type:Individual
Prefix:
First Name:BLASE
Middle Name:
Last Name:VITELLO
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 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-353-7272
Mailing Address - Fax:
Practice Address - Street 1:605 OAK STREET
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307
Practice Address - Country:US
Practice Address - Phone:231-592-4212
Practice Address - Fax:231-592-4343
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010548082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDC0138OtherMEDICARE RR GROUP PIN
MI300E410190OtherBCBS GROUP PIN
MI4503429Medicaid
MI300E410190OtherBCBS GROUP PIN
MI0N79940Medicare PIN
MIDC0138OtherMEDICARE RR GROUP PIN