Provider Demographics
NPI:1952434292
Name:BRUCE D DRAGOO MD PC
Entity Type:Organization
Organization Name:BRUCE D DRAGOO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:FREDA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:LARKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-957-3643
Mailing Address - Street 1:1000 E PARIS AVE SE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3691
Mailing Address - Country:US
Mailing Address - Phone:616-957-3643
Mailing Address - Fax:616-957-0896
Practice Address - Street 1:1000 E PARIS AVE SE
Practice Address - Street 2:SUITE 225
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3691
Practice Address - Country:US
Practice Address - Phone:616-957-3643
Practice Address - Fax:616-957-0896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028716332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301028716OtherSTATE LICENSE NUMBER
MI1083311Medicaid
MIBD028716OtherBC MI ID NUMBER
MI1083311Medicaid
MI4301028716OtherSTATE LICENSE NUMBER
MI1083311Medicaid
0P52200Medicare PIN