Provider Demographics
NPI:1063490621
Name:BRODY, KEVIN ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ALEXANDER
Last Name:BRODY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:38935 ANN ARBOR ROAD
Mailing Address - Street 2:CREDENTIALING/PAYER CONTRACTING SERVICES
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:15855 19 MILE ROAD
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-236-2601
Practice Address - Fax:586-263-2589
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301061861207P00000X
VA0101244238207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4247795Medicaid
MI10-4247810Medicaid
MI10-4247777Medicaid
MI10-4777110Medicaid
11272666OtherCAQH
MI10-4247848Medicaid
MI1063490621Medicaid
MI10-4247820Medicaid
0108236832OtherBCBS PIN
MI10-4247801Medicaid
MI10-4247786Medicaid
MI10-4247839Medicaid
KB061861OtherBCBS
MI10-4247801Medicaid
N87430036Medicare PIN
11272666OtherCAQH
0108236832OtherBCBS PIN