Basic Information
| Provider Information | |||||||||
| NPI: | 1194827808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | JERRY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1487 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169751845 | ||||||||
| FaxNumber: | 6169751870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317284601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 08/17/2010 | ||||||||
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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 | 207PE0004X | 4301057209 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 930035897 | 01 | MI | RAILROAD MEDICARE | OTHER |