Provider Demographics
NPI:1952332769
Name:GORSUCH, KERRY L (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:L
Last Name:GORSUCH
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:616-913-1818
Practice Address - Street 1:1787 GRAND RIDGE CT NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7042
Practice Address - Country:US
Practice Address - Phone:616-913-8601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054541207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4878408Medicaid
MI4117781Medicaid
MI2997348Medicaid
MI3021247Medicaid
MI4878257Medicaid
MI4878785Medicaid
MIF63505Medicare UPIN
MI4117781Medicaid
MI4878408Medicaid