Healthcare Provider Details

I. General information

NPI: 1558364315
Provider Name (Legal Business Name): KERSTI BRUINING M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

IV. Provider business mailing address

3537 W FRONT ST, STE. A
TRAVERSE CITY MI
49684-2317
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-7514
  • Fax: 231-392-0039
Mailing address:
  • Phone: 231-935-9700
  • Fax: 231-935-9706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301062455
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301062455
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: