Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RX0202X | Medical Oncology | 4301085894 | MI |
NPI | 1043416811 |
---|---|
Provider Name | Dr. Sami Brake |
First Address | Grand Rapids, MI 49503-2560 |
Second Address | Grand Rapids, MI 49503-2565 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2007 |
Last Update Date | 24/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03349162 | (05) | NY |