Provider Demographics
NPI:1265537625
Name:BROUTIN, CRISTA (DO)
Entity type:Individual
Prefix:
First Name:CRISTA
Middle Name:
Last Name:BROUTIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-464-0887
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:36123 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1216
Practice Address - Country:US
Practice Address - Phone:734-464-0887
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015704207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI70-0-F32947-0OtherBCBS CPIN #
MICB015704OtherBCBS
MI1265537625OtherNPI #
MI4955211-11Medicaid
MI4955211-11Medicaid
MIP28070079Medicare PIN