Provider Demographics
NPI:1912938689
Name:TRUDELL, GREGORY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOSEPH
Last Name:TRUDELL
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 1:203 EDWIN STREET
Mailing Address - Street 2:P.O. BOX 421
Mailing Address - City:LINWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48634
Mailing Address - Country:US
Mailing Address - Phone:989-213-2684
Mailing Address - Fax:
Practice Address - Street 1:806 S OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1725
Practice Address - Country:US
Practice Address - Phone:989-732-7525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074964207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH72901Medicare UPIN