Basic Information
| Provider Information | |||||||||
| NPI: | 1417995408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAZLE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | MEDICAL ADMINISTRATION | ||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162523242 | ||||||||
| FaxNumber: | 6162520260 | ||||||||
| Practice Location | |||||||||
| Address1: | 1787 GRAND RIDGE CT. NE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167748131 | ||||||||
| FaxNumber: | 6167748204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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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 | 207Q00000X | 4301057607 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 900000696 | 01 | MI | PRIORITY HEALTH | OTHER | 080D17690 | 01 | MI | BLUE SHIELD | OTHER | 4558584 | 01 | MI | AETNA | OTHER | 2957048 | 05 | MI | MEDICAID |