MEDICARE: BIRCH SHORE PRIMARY CARE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1396609467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRCH SHORE PRIMARY CARE PLLC

Provider Business Mailing Address
First Line	:	3021 SCHOEDEL RD
Second Line	:
City	:	MANISTEE
State	:	MI
Zip	:	49660-9753
Country	:	US
Telephone Number	:	231-397-9229
Fax Number	:

Provider Business Practice Location Address
First Line	:	3021 SCHOEDEL RD
Second Line	:
City	:	MANISTEE
State	:	MI
Zip	:	49660-9753
Country	:	US
Telephone Number	:	231-397-9229
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES JAY VANDENBERG IV
Credential	:	D.O.
Telephone Number	:	660-988-0795

Provider Enumeration Date	:	12/12/2025
Last Update Date	:	05/27/2026

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