Provider Demographics
NPI:1700990074
Name:PARKE, ROY B (DO)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:B
Last Name:PARKE
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:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-0437
Mailing Address - Country:US
Mailing Address - Phone:269-695-0262
Mailing Address - Fax:
Practice Address - Street 1:257 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1407
Practice Address - Country:US
Practice Address - Phone:269-695-0262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010822207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0851130095OtherBCBS PROVIDER NUMBER
MI2575222Medicaid
MI010040986OtherRAILROAD MEDICARE #
MI0130815OtherIBA PROVIDER NUMBER
MI0P30260Medicare PIN
MI010040986OtherRAILROAD MEDICARE #