Provider Demographics
NPI:1861474009
Name:MCBRIEN, MARY MELISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY MELISSA
Middle Name:
Last Name:MCBRIEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:M MELISSA
Other - Middle Name:
Other - Last Name:MCBRIEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6900 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 314
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3405
Mailing Address - Country:US
Mailing Address - Phone:248-855-7505
Mailing Address - Fax:248-855-5639
Practice Address - Street 1:6900 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 314
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3405
Practice Address - Country:US
Practice Address - Phone:248-855-7505
Practice Address - Fax:248-855-5639
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301404962207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI278151610Medicaid
06317677041Medicare ID - Type Unspecified
MI278151610Medicaid