Provider Demographics
NPI:1407826241
Name:WEST, BRYAN C (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:C
Last Name:WEST
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:20905 E 12 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-6501
Mailing Address - Country:US
Mailing Address - Phone:586-772-3500
Mailing Address - Fax:586-772-6540
Practice Address - Street 1:20905 E 12 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-6501
Practice Address - Country:US
Practice Address - Phone:586-772-3500
Practice Address - Fax:586-772-6540
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-03-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIBW002032213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4717640Medicaid
38-2777871OtherTAX ID #
MI0007767468OtherAETNA
MI149092OtherGREAT LAKE HEALTH PLAN
MI4717640Medicaid