Provider Demographics
NPI:1760973267
Name:EISAMAN, BRIANNA ALEXIS (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIANNA
Middle Name:ALEXIS
Last Name:EISAMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:BRIANNA
Other - Middle Name:ALEXIS
Other - Last Name:BOURGOIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4294 LAUREL DR
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-8430
Practice Address - Country:US
Practice Address - Phone:616-374-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024914207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program