Provider Demographics
NPI:1952528572
Name:PESHEK, BRIAN ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALEXANDER
Last Name:PESHEK
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 1:1500 ABBOT RD STE 400
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1956
Mailing Address - Country:US
Mailing Address - Phone:517-332-0100
Mailing Address - Fax:517-332-0356
Practice Address - Street 1:1500 ABBOT RD STE 400
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1956
Practice Address - Country:US
Practice Address - Phone:517-332-0100
Practice Address - Fax:517-332-0356
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7733A207Y00000X, 207YX0602X
MI4301080097207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1952528572Medicaid
WYW21458Medicaid
WYW21454Medicaid