MEDICARE: MR. JOSEPH L GAGE LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703077967	MI
2	103TC1900X	Counseling Psychologist	6031014166	MI

General Provider Information

NPI Number	:	1184789737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH L GAGE LPN

Provider Business Mailing Address
First Line	:	736 UNION AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1732
Country	:	US
Telephone Number	:	616-742-0185
Fax Number	:	616-897-5954

Provider Business Practice Location Address
First Line	:	1450 LEONARD ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5515
Country	:	US
Telephone Number	:	616-774-8789
Fax Number	:	616-475-7570

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	05/29/2009

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