Healthcare Provider Details

I. General information

NPI: 1306586771
Provider Name (Legal Business Name): NATHANIEL GERDES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1896
US

IV. Provider business mailing address

7848 HAGADORN LN
CANTON MI
48187-5336
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5151015456APP22
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: