Provider Demographics
NPI:1770763773
Name:BRIAN W SWANTON MD PC
Entity type:Organization
Organization Name:BRIAN W SWANTON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SWANTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-374-7660
Mailing Address - Street 1:4294 LAUREL DR
Mailing Address - Street 2:PO 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2817978Medicaid
MI2817978Medicaid
MI0N93030Medicare PIN