Healthcare Provider Details

I. General information

NPI: 1972612547
Provider Name (Legal Business Name): BRIAN WILLIS SWANTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4294 LAUREL DR
LAKE ODESSA MI
48849-9423
US

IV. Provider business mailing address

4294 LAUREL DR P.O. BOX 578
LAKE ODESSA MI
48849-9423
US

V. Phone/Fax

Practice location:
  • Phone: 616-374-7660
  • Fax: 616-374-0270
Mailing address:
  • Phone: 616-374-7660
  • Fax: 616-374-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301035130
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: