Provider Demographics
NPI:1114029071
Name:BIVENS, WILLIAM BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADLEY
Last Name:BIVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-6913
Mailing Address - Fax:517-841-6917
Practice Address - Street 1:2585 SPRING ARBOR RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3655
Practice Address - Country:US
Practice Address - Phone:517-784-0032
Practice Address - Fax:517-784-8959
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4916975-10Medicaid
MI4917005-10Medicaid
MIP00374256OtherRR MEDICARE
MI4917005-10Medicaid
MI4916975-10Medicaid
MIM50940061Medicare PIN
MII10230Medicare UPIN