Provider Demographics
NPI:1871670257
Name:GULL ROAD MEDICAL PRACTICE, P.C.
Entity Type:Organization
Organization Name:GULL ROAD MEDICAL PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-381-7136
Mailing Address - Street 1:1820 SHAFFER ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1604
Mailing Address - Country:US
Mailing Address - Phone:269-381-7136
Mailing Address - Fax:269-381-6665
Practice Address - Street 1:1820 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1604
Practice Address - Country:US
Practice Address - Phone:269-381-7136
Practice Address - Fax:269-381-6665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C96049Medicare PIN