Healthcare Provider Details

I. General information

NPI: 1114134681
Provider Name (Legal Business Name): GREGERSON RADIOLOGY CONSULTANTS LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8004 RED FOX RD
STANWOOD MI
49346
US

IV. Provider business mailing address

8004 RED FOX RD
STANWOOD MI
49346-9641
US

V. Phone/Fax

Practice location:
  • Phone: 630-854-3367
  • Fax:
Mailing address:
  • Phone: 630-854-3367
  • Fax: 630-578-1018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number038-005324
License Number StateIL

VIII. Authorized Official

Name: DR. DOUGLAS M. GREGERSON
Title or Position: OWNER
Credential: D.A.C.B.R.
Phone: 630-854-3367