Provider Demographics
NPI:1992702542
Name:BURCON, MICHAEL T (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:BURCON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Mailing Address - Street 2:SUITE 252
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5938
Mailing Address - Country:US
Mailing Address - Phone:616-575-9990
Mailing Address - Fax:616-575-9995
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Practice Address - Street 2:SUITE 252
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5938
Practice Address - Country:US
Practice Address - Phone:616-575-9990
Practice Address - Fax:616-575-9995
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950D151480OtherBLUE CROSS
MI4126753Medicaid
MI950D151480OtherBLUE CROSS