Healthcare Provider Details

I. General information

NPI: 1104856046
Provider Name (Legal Business Name): MICHAEL EDWARD BISGROVE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 5TH ST SUITE #1
BROOKINGS OR
97415-9730
US

IV. Provider business mailing address

555 5TH ST SUITE #1
BROOKINGS OR
97415-9730
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-1152
  • Fax: 541-412-1842
Mailing address:
  • Phone: 541-412-1152
  • Fax: 541-412-1842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101039643
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: