Provider Demographics
NPI:1164873527
Name:BRANNICK, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BRANNICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 SPRING ARBOR RD STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-8622
Mailing Address - Country:US
Mailing Address - Phone:517-205-2143
Mailing Address - Fax:517-205-0143
Practice Address - Street 1:3333 SPRING ARBOR RD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-8622
Practice Address - Country:US
Practice Address - Phone:517-205-2143
Practice Address - Fax:517-205-0143
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002806213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery