Healthcare Provider Details

I. General information

NPI: 1346200847
Provider Name (Legal Business Name): BROOKVILLE PEDIATRIC & INTERNAL MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 56TH ST SW
WYOMING MI
49509
US

IV. Provider business mailing address

8485 ALGOMA AVE
ROCKFORD MI
49341
US

V. Phone/Fax

Practice location:
  • Phone: 616-243-5707
  • Fax: 616-243-1170
Mailing address:
  • Phone: 616-243-5707
  • Fax: 616-243-1170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: MRS. APRIL A. KEIZER
Title or Position: ADMINISTRATIVE MANAG
Credential:
Phone: 616-514-3805