Basic Information
Provider Information | |||||||||
NPI: | 1932142262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUNNELL | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1140 N STATE ST | ||||||||
Address2: |   | ||||||||
City: | SAINT IGNACE | ||||||||
State: | MI | ||||||||
PostalCode: | 497811048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9066438585 | ||||||||
FaxNumber: | 9066430414 | ||||||||
Practice Location | |||||||||
Address1: | 1140 N STATE ST | ||||||||
Address2: |   | ||||||||
City: | SAINT IGNACE | ||||||||
State: | MI | ||||||||
PostalCode: | 497811048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9066438585 | ||||||||
FaxNumber: | 9066430414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 03/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | CG060025 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 4880021 | 05 | MI |   | MEDICAID | 0F06016 | 01 | MI | MEDICARE BILL PAY TO | OTHER | 4879998 | 05 | MI |   | MEDICAID | 4880012 | 05 | MI |   | MEDICAID | 4880030 | 05 | MI |   | MEDICAID |