Basic Information
| Provider Information | |||||||||
| NPI: | 1225099161 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | NEAL | ||||||||
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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: | 2060 E PARIS AVE SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495466113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162851377 | ||||||||
| FaxNumber: | 6162851154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 05/03/2012 | ||||||||
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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 | 4301043532 | MI | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4532270-10 | 05 | MI | MEDICAID | 7000027051 | 01 | PRIORITY HEALTH MEDICAID | OTHER | 050044374 | 01 | RAILROAD MEDICARE | OTHER | 11908 | 01 | HEALTH PLAN OF MICHIGAN | OTHER | 4552970-10 | 05 | MI | MEDICAID | 2019450 | 01 | PHYSICIANS HEALTH PLAN | OTHER | 550410724 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 7582081 | 01 | CIGNA | OTHER | 4098753 | 01 | AETNA | OTHER | 7000027051 | 01 | PRIORITY HEALTH | OTHER |