Provider Demographics
NPI:1124070479
Name:BROVIAC, JOHN W (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:BROVIAC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2601 COOLIDGE RD
Mailing Address - Street 2:STE B
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6361
Mailing Address - Country:US
Mailing Address - Phone:517-913-4050
Mailing Address - Fax:517-333-0893
Practice Address - Street 1:2601 COOLIDGE RD
Practice Address - Street 2:STE B
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6361
Practice Address - Country:US
Practice Address - Phone:517-913-4050
Practice Address - Fax:517-333-0893
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-01-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301034184207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M54760003OtherMEDICARE PLUS BLUE
MI1001247OtherMCLAREN HEALTH PLAN-MEDICAID
MI1001247OtherMCLAREN HEALTH ADVANTAGE
MI3421169Medicaid
MI5151077OtherAETNA
MI1001247OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI1103351181OtherBCBS/BCN
MI200000001388OtherPHP
MI200000001388OtherPHP FAMILYCARE
MI110159644OtherRAILROAD MEDICARE
MI194055OtherPHCS
MI3421187Medicaid
MIM54760003Medicare PIN
MI0M54760003OtherMEDICARE PLUS BLUE
MI5151077OtherAETNA