1528094976 NPI number — DR. RENEE SUE BRAYTON DO

Table of content: DR. RENEE SUE BRAYTON DO (NPI 1528094976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528094976 NPI number — DR. RENEE SUE BRAYTON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAYTON
Provider First Name:
RENEE
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1528094976
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 FRANK LLOYD WRIGHT DRIVE
Provider Second Line Business Mailing Address:
SUITE J2000
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-747-6766
Provider Business Mailing Address Fax Number:
734-222-3100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 WHITEHALL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-225-0086
Provider Business Practice Location Address Fax Number:
810-225-0286
Provider Enumeration Date:
06/25/2006

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:  5101012364 , 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: 4748753 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0853302604 . This is a "BCBS INDIVIDUAL PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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