Provider Demographics
NPI:1285659177
Name:BRAGDON, ALLEN C (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:C
Last Name:BRAGDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 71
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-5330
Mailing Address - Fax:616-391-5343
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:MC 845
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072324207PE0004X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285659177Medicaid
MIP00397048OtherRAILROAD MEDICARE
MI930106271OtherRAILROAD MEDICARE
MIE96010073Medicare PIN
MI1285659177Medicaid
MID16094073Medicare PIN
MIH37159Medicare UPIN
MIP00397048OtherRAILROAD MEDICARE