Provider Demographics
NPI:1104863695
Name:BEDARD-LUSIS, MARY PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:BEDARD-LUSIS
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 1:4201 ST. ANTOINE UHC 6F MAILBOX# 226
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2061
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:313-966-6618
Practice Address - Street 1:CHILDRENS HOSPITAL MI NEONATOLOGY
Practice Address - Street 2:3901 BEAUBIEN 2ND FLOOR - MAIN BUILDING
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-1436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039853208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics