Provider Demographics
NPI:1598742686
Name:BRENZ, RICHARD MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MICHAEL
Last Name:BRENZ
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 1:502 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2577
Mailing Address - Country:US
Mailing Address - Phone:231-775-1248
Mailing Address - Fax:231-775-1156
Practice Address - Street 1:502 COBB ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2577
Practice Address - Country:US
Practice Address - Phone:231-775-1248
Practice Address - Fax:231-775-1156
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI054351207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1160590001OtherMEDICARE DMERC
MI180017224OtherMEDICARE RR
MI1808324011OtherBLUE CROSS
MI2933583Medicaid
MI101312OtherPROF CHOICES
08324014182Medicare ID - Type Unspecified
MI2933583Medicaid