Provider Demographics
NPI:1962455188
Name:COLEGROVE, NEIL (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:
Last Name:COLEGROVE
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:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:2373 64TH ST SW
Practice Address - Street 2:SUITE 1300
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-7974
Practice Address - Country:US
Practice Address - Phone:616-685-1350
Practice Address - Fax:616-261-7191
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4786852Medicaid
MI4109850Medicaid
MI4876735Medicaid
MI3403877Medicaid
MI3415573Medicaid
MI2853286Medicaid
MI4166660Medicaid
MI4187786Medicaid
MI4591673Medicaid
MI4179111Medicaid
MI4166660Medicaid
MI4179111Medicaid
MI4591673Medicaid
MI2853286Medicaid