Basic Information
| Provider Information | |||||||||
| NPI: | 1285734459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINNER | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | KENT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | BOX 42 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417806 | ||||||||
| FaxNumber: | 2693418743 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 W COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490153028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699654500 | ||||||||
| FaxNumber: | 2699651150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 08/26/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | BW057232 | MI | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1285734459 | 05 | MI | MEDICAID | 700C910950 | 01 | MI | BCBSM | OTHER | 080101081 | 01 | MI | RAILROAD MEDICARE | OTHER | BW057232 | 01 | MI | BCNBC | OTHER |