Provider Demographics
NPI:1891779401
Name:BRICKNER, ROBERT J JR (MC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:BRICKNER
Suffix:JR
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-5160
Mailing Address - Country:US
Mailing Address - Phone:517-372-0500
Mailing Address - Fax:517-482-3220
Practice Address - Street 1:737 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-5160
Practice Address - Country:US
Practice Address - Phone:517-372-0500
Practice Address - Fax:517-482-3220
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034509208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2099639Medicaid
MI2099639Medicaid
MI0332934Medicare ID - Type Unspecified