Healthcare Provider Details

I. General information

NPI: 1780783282
Provider Name (Legal Business Name): GORDON SRKALOVIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

PO BOX 13008
LANSING MI
48901-3008
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-2890
  • Fax: 517-364-2886
Mailing address:
  • Phone: 517-364-6253
  • Fax: 517-364-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301082787
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: