Provider Demographics
NPI:1225191844
Name:EGGENBERGER, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:EGGENBERGER
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 1:5325 ELLIOTT
Mailing Address - Street 2:SUITE 104, ASSOCIATES IN GENERAL AND VASCULAR SURGERY
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:49197
Mailing Address - Country:US
Mailing Address - Phone:734-712-8150
Mailing Address - Fax:
Practice Address - Street 1:5325 ELLIOTT DR STE 104
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8633
Practice Address - Country:US
Practice Address - Phone:734-712-8150
Practice Address - Fax:734-712-8151
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301405869208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
JE405869OtherCOMMERCIAL-COMMERCIAL NUMBER
JE405869OtherCHAMPUS-CHAMPUS
280H264470OtherBLUE CROSS-BLUE CROSS
MI284751010Medicaid
JE405869OtherCHAMPUS-CHAMPUS
MI284751010Medicaid