Provider Demographics
NPI:1235245002
Name:BRICE, REBECCA M (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:BRICE
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 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:1915 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-9366
Practice Address - Country:US
Practice Address - Phone:574-948-4000
Practice Address - Fax:574-948-5454
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229933207Q00000X
IN02002952A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000939770OtherBCBS PFIM
IN000000939771OtherBCBS MCPEDS
IN000000939770OtherBCBS PFIMD
IN200824340Medicaid
IN000000939766OtherBCBS LSC
IN000000939769OtherBCBS MCFP
IN200824340Medicaid
INM161595003Medicare PIN
IN000000939770OtherBCBS PFIM
IN000000939771OtherBCBS MCPEDS