1245337179 NPI number — AUDREY J BRUELL DERMATOLOGY

Table of content: (NPI 1245337179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245337179 NPI number — AUDREY J BRUELL DERMATOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUDREY J BRUELL DERMATOLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AUDREY J BRUELL MD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245337179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37605 PEMBROKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48152-1050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37605 PEMBROKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48152-1050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-591-7931
Provider Business Practice Location Address Fax Number:
734-464-0335
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DURIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
517-505-0661

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  4301062941 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2368769 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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