Provider Demographics
NPI:1154504884
Name:BROOKSIDE BATTLE CREEK ASSOCIATES PLC
Entity Type:Organization
Organization Name:BROOKSIDE BATTLE CREEK ASSOCIATES PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:GIRARDOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-979-6425
Mailing Address - Street 1:215 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49037-2828
Mailing Address - Country:US
Mailing Address - Phone:269-969-6126
Mailing Address - Fax:269-969-6136
Practice Address - Street 1:215 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-2828
Practice Address - Country:US
Practice Address - Phone:269-969-6126
Practice Address - Fax:269-969-6136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301023701208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619602Medicaid
MION95330Medicare PIN
MI4619602Medicaid