Healthcare Provider Details

I. General information

NPI: 1255040051
Provider Name (Legal Business Name): MR. BRYAN JACOB COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 11/24/2022
Certification Date: 11/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30880 BECK RD
NOVI MI
48377-1000
US

IV. Provider business mailing address

420 N RIDGE ST
SOUTH LYON MI
48178-1133
US

V. Phone/Fax

Practice location:
  • Phone: 248-926-0009
  • Fax:
Mailing address:
  • Phone: 248-514-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number228937373739
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number44352254678
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: