Basic Information
| Provider Information | |||||||||
| NPI: | 1023021615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUGEL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | RONALD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173534911 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 S HAGADORN RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174326144 | ||||||||
| FaxNumber: | 5174326150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 5101010569 | MI | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | 3317699 | 05 | MI | MEDICAID |