Healthcare Provider Details

I. General information

NPI: 1356578710
Provider Name (Legal Business Name): MARCIA AILEEN BOCKBRADER MD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 BAKER RD STE K
DEXTER MI
48130-1163
US

IV. Provider business mailing address

2749 TRAILWOOD LN
ANN ARBOR MI
48105-9743
US

V. Phone/Fax

Practice location:
  • Phone: 734-215-5643
  • Fax: 614-482-4938
Mailing address:
  • Phone: 734-210-1627
  • Fax: 614-482-4938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number35120118
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number4301510627
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number35120118
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301510627
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number35120118
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number4301510627
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: