Provider Demographics
NPI:1528289337
Name:NIEBYLSKI, BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:NIEBYLSKI
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 1:3450 GREENTREE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2543
Mailing Address - Country:US
Mailing Address - Phone:313-664-8316
Mailing Address - Fax:313-664-8777
Practice Address - Street 1:2850 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2643
Practice Address - Country:US
Practice Address - Phone:313-664-8317
Practice Address - Fax:313-664-8777
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042466207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB48208Medicare UPIN
MI700H26222Medicare ID - Type Unspecified