Provider Demographics
NPI:1881701829
Name:LERVICK, GREGORY NEAL (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:NEAL
Last Name:LERVICK
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 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:4010 W 65TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1706
Practice Address - Country:US
Practice Address - Phone:952-456-7000
Practice Address - Fax:952-456-7001
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45031207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN328275900Medicaid
969991032727OtherPREFERREDONE
901659OtherMEDICA
HP35952OtherHEALTHPARTNERS
HP35952OtherHEALTHPARTNERS