Basic Information
Provider Information | |||||||||
NPI: | 1699269027 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROCKBERG | ||||||||
FirstName: | ERICA | ||||||||
MiddleName: | HEISEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 35046 WOODWARD AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | MI | ||||||||
PostalCode: | 480090964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486479860 | ||||||||
FaxNumber: | 2485513130 | ||||||||
Practice Location | |||||||||
Address1: | 3535 W 13 MILE RD STE 140 | ||||||||
Address2: |   | ||||||||
City: | ROYAL OAK | ||||||||
State: | MI | ||||||||
PostalCode: | 480736770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485513000 | ||||||||
FaxNumber: | 2485519426 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2018 | ||||||||
LastUpdateDate: | 06/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301114803 | MI | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.