Healthcare Provider Details

I. General information

NPI: 1265597223
Provider Name (Legal Business Name): SCOTT R BRUNDAGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 EAST PARIS AVENUE SE SUITE 150
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

2060 EAST PARIS AVENUE SE SUITE 150
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-1256
  • Fax: 616-454-0308
Mailing address:
  • Phone: 616-454-1256
  • Fax: 616-454-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number045016
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: