Provider Demographics
NPI:1336261395
Name:POELMAN, GARY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DAVID
Last Name:POELMAN
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 1:3713 NORTON HILLS RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3355 EAGLE PARK DR NE
Practice Address - Street 2:STE103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7004
Practice Address - Country:US
Practice Address - Phone:616-942-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGP043454207PE0004X, 208D00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0107001012OtherBCBS
40099285OtherAETNA
152750OtherPHCS
117141PCOtherCCHMO,CCPPO,MERCY
B43739OtherPRIORITY HEALTH
B43739OtherPRIORITY HEALTH
D16037002Medicare PIN