Basic Information
| Provider Information | |||||||||
| NPI: | 1285671412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUERRERO | ||||||||
| FirstName: | LEVI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3532 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DECKERVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484279615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103763100 | ||||||||
| FaxNumber: | 8103768311 | ||||||||
| Practice Location | |||||||||
| Address1: | 3532 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DECKERVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484279615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103763100 | ||||||||
| FaxNumber: | 8103768311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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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 | 208D00000X | 43010038491 | MI | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 103365954 | 05 | MI | MEDICAID | 5067217 | 01 | MI | AETNA | OTHER | 0107600112 | 01 | MI | BC/BS/BC NETWORK | OTHER |