Provider Demographics
NPI:1114901576
Name:MCCOMB, BRIAN JAY (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAY
Last Name:MCCOMB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 OAKGROVE ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1176
Mailing Address - Country:US
Mailing Address - Phone:231-398-1950
Mailing Address - Fax:231-398-9268
Practice Address - Street 1:5085 ANNA DR STE B&C
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7475
Practice Address - Country:US
Practice Address - Phone:231-935-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
900018330OtherPRIORITY HEALTH
MI0855110425OtherBLUE CROSS BLUE SHIELD MI
MI4566803Medicaid
MIE16002098OtherMEDICARE PTAN
P00093145OtherPALMETTO GBA RR MEDICARE
760743986100OtherCOMMUNITY CHOICE
7885122OtherAETNA
P00093145OtherPALMETTO GBA RR MEDICARE
0N85950Medicare ID - Type Unspecified