Provider Demographics
NPI:1396788774
Name:GREIB, JERRY MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:MICHAEL
Last Name:GREIB
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 1:38935 ANN ARBOR ROAD
Mailing Address - Street 2:CREDENTIALING/PAYER CONTRACTING SERVICES
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:15855 NINETEEN MILE ROAD
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-493-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014273207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114522460Medicaid
11277479OtherCAQH
JG014273OtherBCBS
P00058832Medicare PIN
11277479OtherCAQH
H34920Medicare UPIN