Basic Information
| Provider Information | |||||||||
| NPI: | 1194720284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CERILLI | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 0446 | ||||||||
| Address2: | 24 FRANK LLOYD WRIGHT DR. LOBBY J | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192915150 | ||||||||
| FaxNumber: | 4194796173 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 E. HURON RIVER DR. | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347127017 | ||||||||
| FaxNumber: | 7347122844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 35069105 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | 4301104239 | MI | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0102X | 4301104239 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 7077263 | 01 | AETNA | OTHER | 04572 | 01 | PARAMOUNT | OTHER | 1194720284 | 05 | MI | MEDICAID | P00462488 | 01 | RRMC | OTHER | 000000522576 | 01 | ANTHEM | OTHER | 2482942 | 05 | OH | MEDICAID |