Basic Information
Provider Information | |||||||||
NPI: | 1902083439 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRUEGGEMAN | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PENFOLD | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 500 CAMPUS DRIVE | ||||||||
Address2: |   | ||||||||
City: | HANCOCK | ||||||||
State: | MI | ||||||||
PostalCode: | 499301569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9064831040 | ||||||||
FaxNumber: | 9064831270 | ||||||||
Practice Location | |||||||||
Address1: | 500 CAMPUS DRIVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | HANCOCK | ||||||||
State: | MI | ||||||||
PostalCode: | 499301569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9064831040 | ||||||||
FaxNumber: | 9064831270 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2008 | ||||||||
LastUpdateDate: | 08/31/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085003024 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 5601006262 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 085003024 | 01 | IL | STATE LICENSE | OTHER |