Provider Demographics
NPI:1548244916
Name:BRIAN J MCCOMB DO PLLC
Entity Type:Organization
Organization Name:BRIAN J MCCOMB DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:MCCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-723-9301
Mailing Address - Street 1:1400 E PARKDALE AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9776
Mailing Address - Country:US
Mailing Address - Phone:231-723-9301
Mailing Address - Fax:231-723-1592
Practice Address - Street 1:1400 E PARKDALE AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9776
Practice Address - Country:US
Practice Address - Phone:231-723-9301
Practice Address - Fax:231-723-1592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7885122OtherAETNA
MI0855110425OtherBLUE CROSS BLUE SHIELD MI
P00093145OtherPALMETTO GBA RR MEDICARE
MI4566803Medicaid
900018330OtherPRIORITY HEALTH
760743986100OtherCOMMUNITY CHOICE
0N85950Medicare ID - Type Unspecified
760743986100OtherCOMMUNITY CHOICE