Provider Demographics
NPI:1003832072
Name:BRET G. AUTREY D.O., PLLC
Entity Type:Organization
Organization Name:BRET G. AUTREY D.O., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:AUTREY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-843-3717
Mailing Address - Street 1:7 N ATKINSON DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1953
Mailing Address - Country:US
Mailing Address - Phone:231-843-3717
Mailing Address - Fax:231-845-6198
Practice Address - Street 1:7 N ATKINSON DR
Practice Address - Street 2:SUITE 112
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1953
Practice Address - Country:US
Practice Address - Phone:231-843-3717
Practice Address - Fax:231-845-6198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014946208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4926720Medicaid
MI4926720Medicaid