Basic Information
| Provider Information | |||||||||
| NPI: | 1710079256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOSKOCH | ||||||||
| FirstName: | GERALYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14705 W UPRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315476519 | ||||||||
| FaxNumber: | 2315475404 | ||||||||
| Practice Location | |||||||||
| Address1: | 14705 W UPRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315476520 | ||||||||
| FaxNumber: | 2315475404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 4301065473 | MI | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 4301065473 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 381459366062 | 01 | MI | COMMUNITY CHOICE PIN# | OTHER | 4301065473 | 01 | MI | BC LICENSE NUMBER | OTHER | GD065473 | 01 | MI | BLUE SHIELD LICENSE NUM | OTHER | 4847260 | 05 | MI | MEDICAID |