Provider Demographics
NPI:1134129588
Name:BLUNDEN, ELIZABETH GAIL (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GAIL
Last Name:BLUNDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 771036
Mailing Address - Street 2:P.O. BOX 77000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-0001
Mailing Address - Country:US
Mailing Address - Phone:586-447-4171
Mailing Address - Fax:586-447-4180
Practice Address - Street 1:16815 E JEFFERSON AVE STE 120
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1923
Practice Address - Country:US
Practice Address - Phone:586-498-4400
Practice Address - Fax:586-498-4440
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059826207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4599143-10Medicaid
MIM75620075Medicare ID - Type Unspecified
MI4599143-10Medicaid