Provider Demographics
NPI:1407028608
Name:NANCY J BROOKE MD PC
Entity Type:Organization
Organization Name:NANCY J BROOKE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-447-7200
Mailing Address - Street 1:1525 E BELTLINE AVE NE STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-4598
Mailing Address - Country:US
Mailing Address - Phone:616-447-7200
Mailing Address - Fax:616-447-9773
Practice Address - Street 1:1525 E BELTLINE AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4598
Practice Address - Country:US
Practice Address - Phone:616-447-7200
Practice Address - Fax:616-447-9773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINB049930207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2642755Medicaid