Provider Demographics
NPI:1306965983
Name:AUDREY BRUELL, M.D. P.C.
Entity type:Organization
Organization Name:AUDREY BRUELL, M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:989-666-4775
Mailing Address - Street 1:37605 PEMBROKE
Mailing Address - Street 2:JAMES JAMES TOWNE
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1050
Mailing Address - Country:US
Mailing Address - Phone:734-591-7931
Mailing Address - Fax:734-464-0335
Practice Address - Street 1:37605 PEMBROKE AVE
Practice Address - Street 2:JAMES JAMES TOWNE
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1050
Practice Address - Country:US
Practice Address - Phone:734-591-7931
Practice Address - Fax:734-464-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062941207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID13610Medicare UPIN
MIOM17600Medicare ID - Type Unspecified