Basic Information
| Provider Information | |||||||||
| NPI: | 1568452811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMBROSKE | ||||||||
| FirstName: | OLAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7115 CADE RD | ||||||||
| Address2: | |||||||||
| City: | BROWN CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484169778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103462757 | ||||||||
| FaxNumber: | 8103462016 | ||||||||
| Practice Location | |||||||||
| Address1: | 7115 CADE RD | ||||||||
| Address2: | |||||||||
| City: | BROWN CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484169778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103462757 | ||||||||
| FaxNumber: | 8103462016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0D008339 5101008339 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0157600104 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 1626158 | 05 | MI | MEDICAID |