Provider Demographics
NPI:1275687147
Name:ROY B PARKE D.O.
Entity Type:Organization
Organization Name:ROY B PARKE D.O.
Other - Org Name:BUCHANAN FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ERNSBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-695-5540
Mailing Address - Street 1:1045 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-8474
Mailing Address - Country:US
Mailing Address - Phone:269-695-5540
Mailing Address - Fax:269-695-0412
Practice Address - Street 1:1045 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-8474
Practice Address - Country:US
Practice Address - Phone:269-695-5540
Practice Address - Fax:269-695-0412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010822207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0877052OtherBCBSM PROVIDER #
MI0P302600003OtherBCBSM
MI0P30260006OtherBCBSM
MI5111155OtherBCBSM PROVIDER #
MI0A11219OtherBCBSM PROVIDER #
MI5113009OtherBCBSM PROVIDER #
MI2575222Medicaid
MI5111148OtherBCBSM PROVIDER NUMBER
MI0P30260008Medicare PIN
MI5113009OtherBCBSM PROVIDER #
MI0P30260Medicare ID - Type UnspecifiedMCR GROUP PROVIDER NUMBER
MI5111148OtherBCBSM PROVIDER NUMBER