Provider Demographics
NPI:1407262660
Name:BAISE-BERGERON PC
Entity Type:Organization
Organization Name:BAISE-BERGERON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:SOPHIA
Authorized Official - Last Name:BAISE-BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-943-8290
Mailing Address - Street 1:1365 S MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2217
Mailing Address - Country:US
Mailing Address - Phone:734-927-4411
Mailing Address - Fax:734-927-4410
Practice Address - Street 1:1365 S MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2217
Practice Address - Country:US
Practice Address - Phone:734-927-4411
Practice Address - Fax:734-927-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008419111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950H215320OtherBLUE CROSS