Provider Demographics
NPI:1972612547
Name:SWANTON, BRIAN WILLIS (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIS
Last Name:SWANTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4294 LAUREL DR
Mailing Address - Street 2:P.O. BOX 578
Mailing Address - City:LAKE ODESSA
Mailing Address - State:MI
Mailing Address - Zip Code:48849-9423
Mailing Address - Country:US
Mailing Address - Phone:616-374-7660
Mailing Address - Fax:616-374-0270
Practice Address - Street 1:4294 LAUREL DR
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-9423
Practice Address - Country:US
Practice Address - Phone:616-374-7660
Practice Address - Fax:616-374-0270
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035130208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2817978Medicaid
MI382376508OtherTAX IDENTIFICATION
MI0348293OtherBLUE CROSS BLUE SHIELD MI
MIBS035130OtherSTATE LICENSE MI
MI2817978Medicaid
MI0N93030Medicare ID - Type Unspecified