Provider Demographics
NPI:1679541940
Name:BREITENBACH, RAY ALVIN (MD)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:ALVIN
Last Name:BREITENBACH
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 1:3901 HIGHLAND RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2162
Mailing Address - Country:US
Mailing Address - Phone:248-682-3070
Mailing Address - Fax:248-682-3626
Practice Address - Street 1:3901 HIGHLAND RD
Practice Address - Street 2:SUITE D
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2162
Practice Address - Country:US
Practice Address - Phone:248-682-3070
Practice Address - Fax:248-682-3626
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301404572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F37550OtherBCBSM
MI104680165Medicaid
MI700F37550OtherBCBSM
MI104680165Medicaid