Provider Demographics
NPI:1356434369
Name:MUSOLF, BRENT M (DC)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:M
Last Name:MUSOLF
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 1:3159 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:PORT AUSTIN
Mailing Address - State:MI
Mailing Address - Zip Code:48467-9726
Mailing Address - Country:US
Mailing Address - Phone:989-975-0062
Mailing Address - Fax:
Practice Address - Street 1:305 E HURON AVE STE 9
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1448
Practice Address - Country:US
Practice Address - Phone:989-269-7300
Practice Address - Fax:989-269-7303
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950C21039OtherBCBS
MIMI5267Medicare PIN