Healthcare Provider Details

I. General information

NPI: 1558317446
Provider Name (Legal Business Name): BRIAN ELBERT BATES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 N SAINT JOSEPH AVE SUITE 101
NILES MI
49120-2203
US

IV. Provider business mailing address

PO BOX 708
SAINT JOSEPH MI
49085-0708
US

V. Phone/Fax

Practice location:
  • Phone: 269-684-6696
  • Fax: 269-684-5286
Mailing address:
  • Phone: 269-428-5007
  • Fax: 269-428-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM001208
License Number StateGU
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301407413
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: