Healthcare Provider Details

I. General information

NPI: 1164611836
Provider Name (Legal Business Name): GARY W BAILEY DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 BURTON ST SE
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

2525 BURTON ST SE
GRAND RAPIDS MI
49546-4834
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-2410
  • Fax: 616-957-2411
Mailing address:
  • Phone: 616-957-2410
  • Fax: 616-957-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101007477
License Number StateMI

VIII. Authorized Official

Name: GARY WILLIS BAILEY
Title or Position: PHYSICIAN/OWNER
Credential:
Phone: 616-957-2410