=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639174071
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG BROCKMAN N.P.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2005
-----------------------------------------------------
Last Update Date | 03/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11775 TECUMSEH CLINTON RD
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49236-9541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-456-7449
-----------------------------------------------------
Fax | 517-456-6059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8770 HAWTHORNE DR
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49286-9504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704166180
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------