Provider Demographics
NPI:1184636953
Name:EBROM, JOHN STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STEPHEN
Last Name:EBROM
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:PO BOX 77000
Mailing Address - Street 2:DEPT #77339
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-0339
Mailing Address - Country:US
Mailing Address - Phone:616-364-6700
Mailing Address - Fax:616-364-4960
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-364-6700
Practice Address - Fax:616-364-4960
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044412207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4525177100Medicaid
MIP00009267OtherRR MEDICARE
MI0N73070Medicare ID - Type Unspecified
B46573Medicare UPIN