Provider Demographics
NPI:1184604795
Name:DETOLVE, GEOFFREY R (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:R
Last Name:DETOLVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE E352
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8986
Mailing Address - Fax:269-341-6236
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE E352
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8986
Practice Address - Fax:269-341-6236
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301064382208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1184604795Medicaid
MI4385657Medicaid
MI1417961137OtherBCBSM - BMH TAX ID# 38-1359087
D14585Medicare UPIN
MIC97618216Medicare PIN
MI4385657Medicaid