Provider Demographics
NPI:1336156603
Name:BURANDT, TIMOTHY M (DO, FACOS, FACS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:M
Last Name:BURANDT
Suffix:
Gender:M
Credentials:DO, FACOS, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27118 WALLOON WAY
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48134-8071
Mailing Address - Country:US
Mailing Address - Phone:734-795-7032
Mailing Address - Fax:734-795-7032
Practice Address - Street 1:5400 FORT ST
Practice Address - Street 2:SUITE #150
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4632
Practice Address - Country:US
Practice Address - Phone:734-671-3678
Practice Address - Fax:734-671-3679
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008170208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2953577Medicaid
MIM97860002OtherMEDICARE ID TYPE UNSPECIFIED
MI2953577Medicaid