Basic Information
Provider Information | |||||||||
NPI: | 1487620050 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KERGES | ||||||||
FirstName: | DANA | ||||||||
MiddleName: | GEORGETA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MARINCAT | ||||||||
OtherFirstName: | DANA | ||||||||
OtherMiddleName: | GEORGETA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 26901 BEAUMONT BLVD | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480333849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9475221867 | ||||||||
FaxNumber: | 9475220307 | ||||||||
Practice Location | |||||||||
Address1: | 8545 COMMON RD STE 280 | ||||||||
Address2: |   | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480936775 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5863933025 | ||||||||
FaxNumber: | 5863933008 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/24/2006 | ||||||||
LastUpdateDate: | 10/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301081809 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.