Provider Demographics
NPI:1386094548
Name:BLAZIUS, BROOKE (DO)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BLAZIUS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5000
Practice Address - Country:US
Practice Address - Phone:734-936-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024606208000000X, 2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty