Provider Demographics
NPI:1811032147
Name:BELLER, BRYAN D (DC)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:D
Last Name:BELLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 NORTHLINE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2407
Mailing Address - Country:US
Mailing Address - Phone:734-225-1505
Mailing Address - Fax:734-225-1504
Practice Address - Street 1:14701 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2407
Practice Address - Country:US
Practice Address - Phone:734-225-1505
Practice Address - Fax:734-225-1504
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005813111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3151958Medicaid
MI950H25342OtherBLUE CROSS BLUE SHEILD
MIM05160001Medicare PIN
MI3151958Medicaid