Basic Information
| Provider Information | |||||||||
| NPI: | 1952332769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORSUCH | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6169131818 | ||||||||
| Practice Location | |||||||||
| Address1: | 1787 GRAND RIDGE CT NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495257042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169138601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207V00000X | 4301054541 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 4878408 | 05 | MI | MEDICAID | 4117781 | 05 | MI | MEDICAID | 2997348 | 05 | MI | MEDICAID | 3021247 | 05 | MI | MEDICAID | 4878257 | 05 | MI | MEDICAID | 4878785 | 05 | MI | MEDICAID |