Provider Demographics
NPI:1710966783
Name:PAGE, ROBERT BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRUCE
Last Name:PAGE
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 1:5082 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1557
Mailing Address - Country:US
Mailing Address - Phone:269-381-0118
Mailing Address - Fax:269-381-4610
Practice Address - Street 1:5082 LOVERS LN
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1557
Practice Address - Country:US
Practice Address - Phone:269-381-0118
Practice Address - Fax:269-381-4610
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050795208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2997419Medicaid
MI3503909888OtherBLUE CROSS PIN #
MI1230259OtherPHP
MIP68785OtherBLUE CHOICE
MI4301050795OtherMI PHYSICIAN NUMBER
MI4301050795OtherMI PHYSICIAN NUMBER
MI2997419Medicaid