Provider Demographics
NPI:1114039526
Name:BARBOUR, EDMUND MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:MARTIN
Last Name:BARBOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1505
Mailing Address - Country:US
Mailing Address - Phone:313-562-2247
Mailing Address - Fax:313-792-1846
Practice Address - Street 1:939 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1505
Practice Address - Country:US
Practice Address - Phone:313-562-2247
Practice Address - Fax:313-792-1846
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI028846207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1051532Medicaid
MI3827195Medicare ID - Type Unspecified
MI1051532Medicaid