Provider Demographics
NPI:1386602761
Name:BARBOUR, BRUCE STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:STEPHEN
Last Name:BARBOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E MICHIGAN AVE
Mailing Address - Street 2:STE 106
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2457
Mailing Address - Country:US
Mailing Address - Phone:517-787-1995
Mailing Address - Fax:517-789-8657
Practice Address - Street 1:900 E MICHIGAN AVE
Practice Address - Street 2:STE 106
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2457
Practice Address - Country:US
Practice Address - Phone:517-787-1995
Practice Address - Fax:517-789-8657
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053463207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104492530Medicaid
MI1103802101OtherBCBSM
MI110107482OtherRAILROAD MEDICARE
MIN53130027Medicare PIN
MI1103802101OtherBCBSM
MI104492530Medicaid