Provider Demographics
NPI:1316983018
Name:EGGEBRECHT, MICHAEL E (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:EGGEBRECHT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 PEACE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9146
Mailing Address - Country:US
Mailing Address - Phone:269-429-5000
Mailing Address - Fax:269-429-2598
Practice Address - Street 1:2500 NILES ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-429-5000
Practice Address - Fax:269-429-2598
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011060207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI293076011Medicaid
N75800002Medicare ID - Type Unspecified
MI293076011Medicaid