Provider Demographics
NPI:1902025760
Name:FITZGIBBON, PATRICK JAMES (DO)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:JAMES
Last Name:FITZGIBBON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 221
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:2373 64TH ST SW
Practice Address - Street 2:STE 1200
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315
Practice Address - Country:US
Practice Address - Phone:616-685-3910
Practice Address - Fax:616-249-0736
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101017026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP32930313Medicare PIN
MIM02830191Medicare PIN