Healthcare Provider Details

I. General information

NPI: 1902905862
Provider Name (Legal Business Name): STEPHEN RODERICK GUERTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

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 373
OKEMOS MI
48805-0373
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-2117
  • Fax: 517-364-3994
Mailing address:
  • Phone: 517-364-2117
  • Fax: 517-364-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number45162
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: