1477748184 NPI number — BOBBI EDWARDS MD PC

Table of content: (NPI 1477748184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477748184 NPI number — BOBBI EDWARDS MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOBBI EDWARDS MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477748184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19315 W 10 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-6596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-483-8488
Provider Business Mailing Address Fax Number:
248-325-8967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24901 NORTHWESTERN HWY
Provider Second Line Business Practice Location Address:
SUITE 214
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-483-8488
Provider Business Practice Location Address Fax Number:
248-483-8489
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
BOBBI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-483-8486

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  BE063204 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0706339290 . This is a "BLUE CROSS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 264628YMPJ . This is a "MARYLAND DC MEDICARE PIN NUMBER" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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