Provider Demographics
NPI:1144229535
Name:VANDERBROEK, MARCIA LYNNE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:LYNNE
Last Name:VANDERBROEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3272 WEST RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2322
Mailing Address - Country:US
Mailing Address - Phone:734-676-7900
Mailing Address - Fax:734-676-0335
Practice Address - Street 1:3272 WEST RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2322
Practice Address - Country:US
Practice Address - Phone:734-676-7900
Practice Address - Fax:734-676-0335
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5820325OtherBLUE CROSS/BLUE SHIELD
MI3927OtherHAP
MI4321696Medicaid
MI383607563OtherTAX ID
MIE74913Medicare UPIN
MI383607563OtherTAX ID
MI4321696Medicaid