MEDICARE: DR. KERSTI BRUINING M.D.

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	174400000X	Specialist	4301062455	MI
2	2084N0400X	Neurology Physician	4301062455	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4301062455	OTHER	MI	STATE LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0281047	OTHER	MI	BCBS NUMBER

General Provider Information

NPI Number	:	1558364315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KERSTI BRUINING M.D.

Provider Business Mailing Address
First Line	:	3537 W FRONT ST, STE. A
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2317
Country	:	US
Telephone Number	:	231-935-9700
Fax Number	:	231-935-9706

Provider Business Practice Location Address
First Line	:	1105 SIXTH ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2345
Country	:	US
Telephone Number	:	231-935-7514
Fax Number	:	231-392-0039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	10/05/2023

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