Provider Demographics
NPI:1205894557
Name:BRANCH, GARY L (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:BRANCH
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 1:819 N SHIAWASSEE ST STE 210
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1601
Mailing Address - Country:US
Mailing Address - Phone:989-541-2663
Mailing Address - Fax:989-723-3601
Practice Address - Street 1:819 N SHIAWASSEE ST STE 210
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1601
Practice Address - Country:US
Practice Address - Phone:989-541-2663
Practice Address - Fax:989-723-3601
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013772208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1205894557Medicaid
MI4508739Medicaid
2557801415OtherBCBSM PIN
0550210001Medicare NSC
2557801415OtherBCBSM PIN
0M09140006Medicare PIN