Provider Demographics
NPI:1154384931
Name:BREITWEISER, KARL O (DO)
Entity type:Individual
Prefix:
First Name:KARL
Middle Name:O
Last Name:BREITWEISER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:ATTN: MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7686 GEORGETOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8101
Practice Address - Country:US
Practice Address - Phone:616-252-8600
Practice Address - Fax:616-252-8660
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154384931Medicaid
MIG23799Medicare UPIN
MIM53750005Medicare PIN
MI08-5-70-0058-5OtherBCBS PIN