Basic Information
| Provider Information | |||||||||
| NPI: | 1154514602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCKLEY | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FORD PL STE 2E | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744806 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2333 BIDDLE AVE | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342466000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2007 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4301502392 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | D0066466 | MD | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 91645102 | 01 | CAREFIRST MARYLAND | OTHER | 607156013 | 01 | DEPT OF LABOR | OTHER | 413562800 | 05 | MD | MEDICAID | V7930013 | 01 | CAREFIRST DC | OTHER |