Provider Demographics
NPI:1699957571
Name:BROOKSIDE FAMILY MEDICINE A CENTER FOR HEALTH AND WELL-BEING PLC
Entity type:Organization
Organization Name:BROOKSIDE FAMILY MEDICINE A CENTER FOR HEALTH AND WELL-BEING PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GRAETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-922-0400
Mailing Address - Street 1:647 E EIGHTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2630
Mailing Address - Country:US
Mailing Address - Phone:231-922-0400
Mailing Address - Fax:855-586-8399
Practice Address - Street 1:647 E EIGHTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2630
Practice Address - Country:US
Practice Address - Phone:231-922-0400
Practice Address - Fax:855-586-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4102107Medicaid
MI0280363OtherBLUE CARE NETWORK
MI0B810140OtherBCBS OF MI GROUP
MI0280363OtherBLUE CARE NETWORK
MI=========OtherPRIORITY HEALTH
MI0B810140OtherBCBS OF MI GROUP
MI4102107Medicaid