Basic Information
| Provider Information | |||||||||
| NPI: | 1295847739 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLEIL | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696392910 | ||||||||
| FaxNumber: | 2696392919 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696392910 | ||||||||
| FaxNumber: | 2696392919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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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 | 207Q00000X | 056047 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2937733 | 05 | MI | MEDICAID | 080064237 | 01 | MI | RR MEDICARE | OTHER | 0131167 | 01 | MI | PHP/IBA | OTHER | P77691 | 01 | MI | BCN | OTHER | 5976083 | 01 | MI | AETNA | OTHER | 080H06004 | 01 | MI | BCBSM | OTHER |