Healthcare Provider Details

I. General information

NPI: 1093779670
Provider Name (Legal Business Name): BRIAN A MCCARROLL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80600 VAN DYKE RD
BRUCE TWP MI
48065-1333
US

IV. Provider business mailing address

80600 VAN DYKE RD
BRUCE TWP MI
48065-1333
US

V. Phone/Fax

Practice location:
  • Phone: 810-798-6560
  • Fax: 810-798-6563
Mailing address:
  • Phone: 810-798-6560
  • Fax: 810-798-6563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBM007710
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: