1578568317 NPI number — BRUCE DOUGLAS DRAGOO MD

Table of content: BRUCE DOUGLAS DRAGOO MD (NPI 1578568317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578568317 NPI number — BRUCE DOUGLAS DRAGOO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRAGOO
Provider First Name:
BRUCE
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1578568317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/03/2020
NPI Reactivation Date:
03/11/2021

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 EAST PARIS SE
Provider Second Line Business Mailing Address:
STE 225
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-957-3643
Provider Business Mailing Address Fax Number:
616-957-0896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 EAST PARIS SE
Provider Second Line Business Practice Location Address:
STE 225
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-957-3643
Provider Business Practice Location Address Fax Number:
616-957-0896
Provider Enumeration Date:
06/17/2005

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: 207W00000X , with the licence number:  4301028716 , 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: 1083311 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4301028716 . This is a "MI STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 180D117670 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382237488 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: BD028716 . This is a "MI BCBS STAT LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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