Provider Demographics
NPI:1497789010
Name:HEERINGA, BRIAN D (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:D
Last Name:HEERINGA
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 1:880 MUNSON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3661
Mailing Address - Country:US
Mailing Address - Phone:231-946-1488
Mailing Address - Fax:231-946-1489
Practice Address - Street 1:880 MUNSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3661
Practice Address - Country:US
Practice Address - Phone:231-946-1488
Practice Address - Fax:231-946-1489
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBH076613208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4759050Medicaid
020H310060OtherBLUE CROSS
020H310060OtherBLUE CROSS
I36373Medicare UPIN