1083618425 NPI number — MELISSA A BROEDERS P.A.-C

Table of content: MELISSA A BROEDERS P.A.-C (NPI 1083618425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083618425 NPI number — MELISSA A BROEDERS P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROEDERS
Provider First Name:
MELISSA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1083618425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 EXPLORER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GWINN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49841-2813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-346-4924
Provider Business Mailing Address Fax Number:
906-346-6474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1414 W FAIR AVE
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-5406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-225-4500
Provider Business Practice Location Address Fax Number:
906-225-3919
Provider Enumeration Date:
06/13/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  5601004115 , 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)