Provider Demographics
NPI:1609472240
Name:BRODBECK, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BRODBECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8247 PAWNEE TRL
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-9396
Mailing Address - Country:US
Mailing Address - Phone:810-819-6222
Mailing Address - Fax:
Practice Address - Street 1:8247 PAWNEE TRL
Practice Address - Street 2:
Practice Address - City:PINCKNEY
Practice Address - State:MI
Practice Address - Zip Code:48169-9396
Practice Address - Country:US
Practice Address - Phone:810-819-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704196726163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice