Provider Demographics
NPI:1154619286
Name:HALES, BRIAN M (OD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:HALES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 N MCEWAN ST # B
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1196
Mailing Address - Country:US
Mailing Address - Phone:989-386-2020
Mailing Address - Fax:989-386-7308
Practice Address - Street 1:1520 N MCEWAN ST # B
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1196
Practice Address - Country:US
Practice Address - Phone:989-386-2020
Practice Address - Fax:989-386-7308
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A80041OtherBLUECROSS BLUESHIELD OF MICHIGAN
MI1154619286Medicaid
MIP01126593OtherRAILROAD MEDICARE
MIMI6157001Medicare UPIN
MI0A80041OtherBLUECROSS BLUESHIELD OF MICHIGAN