Provider Demographics
NPI:1295796555
Name:CARL, BRUCE EDWARD (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:CARL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:43750 GARFIELD RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1135
Mailing Address - Country:US
Mailing Address - Phone:586-226-6860
Mailing Address - Fax:586-226-6880
Practice Address - Street 1:64580 VAN DYKE RD
Practice Address - Street 2:SUITE C
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2857
Practice Address - Country:US
Practice Address - Phone:586-752-9629
Practice Address - Fax:586-752-4099
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-05-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301042852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4373763Medicaid
MI700E012740OtherBCBS GROUP NUMBER
MI700E012740OtherBCBS GROUP NUMBER
MI4373763Medicaid