Provider Demographics
NPI:1407806581
Name:ROCHEFORT, BRUCE JOHN
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:JOHN
Last Name:ROCHEFORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1865
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-593-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066005207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4312650Medicaid
MI7772271OtherAETNA
MIP104516OtherBCN
MI138527OtherGREAT LAKES HEALTH PLAN
MI104363524Medicaid
MI47190OtherOMNICARE HEALTH PLAN
MI160H261380OtherBCBSM/BCN