Healthcare Provider Details

I. General information

NPI: 1609807627
Provider Name (Legal Business Name): KEVIN R BRADER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BYRON CENTER AVE SW
WYOMING MI
49519-9606
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-350-2697
  • Fax:
Mailing address:
  • Phone: 616-252-3243
  • Fax: 616-252-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number4301083612
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: