MEDICARE: GERRIT VANDERLUGT D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	GV007721	MI
2	207Q00000X	Family Medicine Physician	5101007721	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1020574	OTHER	MI	MCLAREN HEALTH PLAN
2	0852914964	OTHER	MI	BCBSM
3	200000005905	OTHER	MI	PHP COMMERCIAL
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	0983154	OTHER	MI	HEALTHPLUS COMMERCIAL

General Provider Information

NPI Number	:	1477550689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERRIT VANDERLUGT D.O.

Provider Business Mailing Address
First Line	:	224 N MILL ST
Second Line	:
City	:	SAINT LOUIS
State	:	MI
Zip	:	48880-1523
Country	:	US
Telephone Number	:	989-681-3524
Fax Number	:	989-681-2683

Provider Business Practice Location Address
First Line	:	224 N MILL ST
Second Line	:
City	:	SAINT LOUIS
State	:	MI
Zip	:	48880-1523
Country	:	US
Telephone Number	:	989-681-3524
Fax Number	:	989-681-2683

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	06/26/2012

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Directions to “ GERRIT VANDERLUGT D.O.” Practice Location

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