Provider Demographics
NPI:1437101300
Name:BOWDITCH, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:BOWDITCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 GULL RD
Mailing Address - Street 2:MSB 015
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1650
Mailing Address - Country:US
Mailing Address - Phone:269-226-6933
Mailing Address - Fax:269-226-6949
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:MSB 015
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-226-6933
Practice Address - Fax:269-226-6949
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053609207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0807510731OtherBC BS OF MI
MI104155782Medicaid
MI1437101300Medicaid
MIBB053609OtherBLUE CROSS BLUE SHIELD
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MI3172340-10Medicaid
MI3172340-10Medicaid
MI0M57650Medicare PIN
MI104155782Medicaid
MI930090555Medicare PIN
MI0807510731OtherBC BS OF MI
MIBB053609OtherBLUE CROSS BLUE SHIELD
MIG56008 069Medicare ID - Type UnspecifiedTHREE RIVERS HEALTH