Provider Demographics
NPI:1568671857
Name:JACKSON ORTHOPEDIC SPECIALIST
Entity type:Organization
Organization Name:JACKSON ORTHOPEDIC SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAUTIGAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-780-9257
Mailing Address - Street 1:1100 E MICHIGAN AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1847
Mailing Address - Country:US
Mailing Address - Phone:517-787-3900
Mailing Address - Fax:517-787-4318
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1847
Practice Address - Country:US
Practice Address - Phone:517-787-3900
Practice Address - Fax:517-787-4318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRB072498174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4637511Medicaid
MION94840Medicare ID - Type Unspecified
MI4637511Medicaid