Provider Demographics
NPI:1023045382
Name:DY, EDELWINA (MD)
Entity Type:Individual
Prefix:DR
First Name:EDELWINA
Middle Name:
Last Name:DY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 E CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-2041
Mailing Address - Country:US
Mailing Address - Phone:517-279-5400
Mailing Address - Fax:
Practice Address - Street 1:358 E CHICAGO ST
Practice Address - Street 2:SUITE 202
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2072
Practice Address - Country:US
Practice Address - Phone:517-279-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058822208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3501243571OtherBCBS PIN
MI1231657OtherPHP/IBA
MI3243942Medicaid