Basic Information
| Provider Information | |||||||||
| NPI: | 1144281080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 COMMERCE AVE SW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400660 | ||||||||
| FaxNumber: | 6169401965 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 LAKE DR SE | ||||||||
| Address2: | STE 305 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162851377 | ||||||||
| FaxNumber: | 6162851006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 11/18/2008 | ||||||||
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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 | 208VP0014X | 4301044533 | MI | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4532350-10 | 05 | MI | MEDICAID | 5648777 | 01 | CIGNA | OTHER | 4592438-10 | 05 | MI | MEDICAID | 23113 | 01 | HEALTH PLAN OF MICHIGAN | OTHER | 4507437-10 | 05 | MI | MEDICAID | 550410072 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | P00057547 | 01 | RAILROAD MEDICARE | OTHER | 7000144071 | 01 | PRIORITY HEALTH | OTHER | 4642669 | 01 | AETNA | OTHER |