Provider Demographics
NPI:1376556258
Name:BRISKO, BEVERLY-JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:BEVERLY-JEAN
Middle Name:
Last Name:BRISKO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:BRISKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPT 203401
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48267-0001
Practice Address - Country:US
Practice Address - Phone:952-442-9770
Practice Address - Fax:952-442-3630
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120347367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104486284Medicaid
MIBB120347OtherBLUE CROSS OF MI
MI104486284Medicaid
MI430079578Medicare PIN