Provider Demographics
NPI:1922030063
Name:GRAESER, RONALD E (DO)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:E
Last Name:GRAESER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1190
Mailing Address - Country:US
Mailing Address - Phone:231-873-5675
Mailing Address - Fax:231-873-3448
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1190
Practice Address - Country:US
Practice Address - Phone:231-873-5675
Practice Address - Fax:231-873-3448
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRG006295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI010F476090OtherBCBS
MI4506190 TYPE 11Medicaid
MI5700059OtherBCBS PIN NUMBER
MIP00004279OtherRAILROAD MEDICARE NUMBER
MI0F47609 009Medicare ID - Type Unspecified
MI4506190 TYPE 11Medicaid