Provider Demographics
NPI:1497775514
Name:VANASSCHE, BRADLEY T (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:VANASSCHE
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 1:1114 CHARLEVOIX AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9701
Mailing Address - Country:US
Mailing Address - Phone:231-439-9700
Mailing Address - Fax:231-439-9709
Practice Address - Street 1:1114 CHARLEVOIX AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9701
Practice Address - Country:US
Practice Address - Phone:231-439-9700
Practice Address - Fax:231-439-9709
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010558472085R0202X
MIBV0558472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3152928Medicaid
MIP00957391OtherRR MEDICARE PTAN
MI300Z460020OtherBLUE CROSS
MIP25410004Medicare PIN
MIP34680003Medicare PIN
MIG09035Medicare UPIN
MI3152928Medicaid