Healthcare Provider Details

I. General information

NPI: 1134440845
Provider Name (Legal Business Name): GREGORY J MCBRIDE D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14695 PARK AVE
CHARLEVOIX MI
49720-1920
US

IV. Provider business mailing address

14695 PARK AVE
CHARLEVOIX MI
49720-1920
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-2812
  • Fax: 231-547-3067
Mailing address:
  • Phone: 989-620-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101018669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: