Provider Demographics
NPI:1558364315
Name:BRUINING, KERSTI (MD)
Entity Type:Individual
Prefix:DR
First Name:KERSTI
Middle Name:
Last Name:BRUINING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 W FRONT ST, STE. A
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2317
Mailing Address - Country:US
Mailing Address - Phone:231-935-9700
Mailing Address - Fax:231-935-9706
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-7514
Practice Address - Fax:231-392-0039
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062455174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301062455OtherSTATE LICENSE NUMBER
MI4618392Medicaid
MI0281047OtherBCBS NUMBER
MIE86324Medicare UPIN
MI4301062455OtherSTATE LICENSE NUMBER