1316093529 NPI number — DR. GWEN MARIE BRANDT MD

Table of content: DR. GWEN MARIE BRANDT MD (NPI 1316093529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316093529 NPI number — DR. GWEN MARIE BRANDT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANDT
Provider First Name:
GWEN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VELDHOF
Provider Other First Name:
GWEN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316093529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 STATE ST SE
Provider Second Line Business Mailing Address:
STE 228
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-685-1808
Provider Business Mailing Address Fax Number:
616-685-1850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 JEFFERSON SE
Provider Second Line Business Practice Location Address:
STE 549
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-685-1835
Provider Business Practice Location Address Fax Number:
616-685-1846
Provider Enumeration Date:
01/28/2007

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: 207Q00000X , with the licence number:  4301085852 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X , with the licence number: 4301085852 , 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)





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