Provider Demographics
NPI:1467569475
Name:LANGERAK, BRUCE A (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:LANGERAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EAST PARIS AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:616-459-3158
Mailing Address - Fax:616-988-0071
Practice Address - Street 1:1000 EAST PARIS AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-459-3158
Practice Address - Fax:616-988-0071
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013735207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154102825OtherBCBS OF MICHIGAN
MI4402177Medicaid
MI1154102825OtherBCBS OF MICHIGAN
MI0D16122023Medicare PIN
38-2145264OtherIRS TAX ID# THRU CORP