Provider Demographics
NPI:1700070067
Name:BECKLIN, BRENT A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:A
Last Name:BECKLIN
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
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 1:8501 MEADOW CRK
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7524
Practice Address - Country:US
Practice Address - Phone:616-267-7884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301102203207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00434378OtherMEDICARE RAILROAD PROV NO
MI1700070067Medicaid
FL279302400Medicaid
MIM74460836Medicare PIN
FLAF976ZMedicare PIN
FLAF976YMedicare PIN