Healthcare Provider Details

I. General information

NPI: 1538532379
Provider Name (Legal Business Name): BRIAN BIGELOW PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 03/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34841 VETERANS PLZ
WAYNE MI
48184-1733
US

IV. Provider business mailing address

34841 VETERANS PLZ
WAYNE MI
48184-1733
US

V. Phone/Fax

Practice location:
  • Phone: 734-728-3446
  • Fax:
Mailing address:
  • Phone: 734-728-3446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704205492
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: