Provider Demographics
NPI:1558317446
Name:BATES, BRIAN ELBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ELBERT
Last Name:BATES
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:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-0708
Mailing Address - Country:US
Mailing Address - Phone:269-428-5007
Mailing Address - Fax:269-428-2789
Practice Address - Street 1:42 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2203
Practice Address - Country:US
Practice Address - Phone:269-684-6696
Practice Address - Fax:269-684-5286
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM001208208600000X
MI4301407413208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1558317446Medicaid
GUE68090Medicare UPIN
GUH51304Medicare PIN