Basic Information
| Provider Information | |||||||||
| NPI: | 1609084938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIDALGO | ||||||||
| FirstName: | DORALIZ | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX Q | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495014917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 JEFFERSON AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301089463 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 4301089463 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | P00443249 | 01 | RAILROAD MEDICARE | OTHER | 5208263 | 05 | MI | MEDICAID | DH089463 | 01 | MI | BCBS | OTHER |