Provider Demographics
NPI:1346200847
Name:BROOKVILLE PEDIATRIC & INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:BROOKVILLE PEDIATRIC & INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MANAG
Authorized Official - Prefix:MRS
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KEIZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-514-3805
Mailing Address - Street 1:8485 ALGOMA AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341
Mailing Address - Country:US
Mailing Address - Phone:616-243-5707
Mailing Address - Fax:616-243-1170
Practice Address - Street 1:1200 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509
Practice Address - Country:US
Practice Address - Phone:616-243-5707
Practice Address - Fax:616-243-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID #