Basic Information
| Provider Information | |||||||||
| NPI: | 1316978877 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VERCRUYSSE | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | ALEC | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DR | ||||||||
| Address2: | 2ND FLOOR TAUBMAN CENTER RECP F | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349365738 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | L7591 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 4301070008 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | L7591 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | L7591 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0102X | 4301070008 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | P00063023 | 01 | TX | RAILROAD MEDICARE | OTHER | 8K1490 | 01 | TX | BCBS | OTHER | 165618301 | 05 | TX | MEDICAID |