Basic Information
| Provider Information | |||||||||
| NPI: | 1962455188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEGROVE | ||||||||
| FirstName: | NEIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | 6166851850 | ||||||||
| Practice Location | |||||||||
| Address1: | 2373 64TH ST SW | ||||||||
| Address2: | SUITE 1300 | ||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493157974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851350 | ||||||||
| FaxNumber: | 6162617191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/26/2009 | ||||||||
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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 | 4301044816 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4786852 | 05 | MI | MEDICAID | 4109850 | 05 | MI | MEDICAID | 4876735 | 05 | MI | MEDICAID | 3403877 | 05 | MI | MEDICAID | 3415573 | 05 | MI | MEDICAID | 2853286 | 05 | MI | MEDICAID | 4166660 | 05 | MI | MEDICAID | 4187786 | 05 | MI | MEDICAID | 4591673 | 05 | MI | MEDICAID | 4179111 | 05 | MI | MEDICAID |