Basic Information
| Provider Information | |||||||||
| NPI: | 1578506408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 GREEN RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481051598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349953764 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2333 BIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132849400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 06/04/2008 | ||||||||
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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 | 207PE0004X | 034428 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 104701247 | 05 | MI | MEDICAID | 103438380 | 05 | MI | MEDICAID | 103370112 | 05 | MI | MEDICAID | 101436126 | 05 | MI | MEDICAID | 102849748 | 05 | MI | MEDICAID | GH034428 | 01 | MI | BLUE SHIELD | OTHER |