Provider Demographics
NPI:1992709562
Name:BRASSEUR, SCOTT B (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:B
Last Name:BRASSEUR
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 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1108 W STATE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9711
Practice Address - Country:US
Practice Address - Phone:269-945-0922
Practice Address - Fax:269-945-4511
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051816207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4956827Medicaid
MI0P39600Medicare PIN
MIE80216Medicare UPIN
MIDF5489OtherPALMETTO GBA RAILROAD