MEDICARE: DR. GREGORY L FLENTJE M.D. PHD

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	2084P0804X	Child & Adolescent Psychiatry Physician	4301078568	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	380001205	OTHER	MI	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	260D110830	OTHER	MI	BLUE CROSS AND BLUE SHIEL

General Provider Information

NPI Number	:	1669405163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY L FLENTJE M.D. PHD

Provider Business Mailing Address
First Line	:	1403 60TH ST SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49508-7065
Country	:	US
Telephone Number	:	616-719-4488
Fax Number	:	616-719-4480

Provider Business Practice Location Address
First Line	:	1403 60TH ST SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49508-7065
Country	:	US
Telephone Number	:	616-719-4488
Fax Number	:	616-719-4480

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

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	06/24/2010

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