Provider Demographics
NPI:1952321556
Name:BRUMMELER, CHARLES J (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:BRUMMELER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 1:605 OAK ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2048
Practice Address - Country:US
Practice Address - Phone:231-592-4245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M01220028Medicare ID - Type Unspecified
MIG86777Medicare UPIN
MI412056211Medicaid