Provider Demographics
NPI:1366645574
Name:ITAWI, ED ADEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ED
Middle Name:ADEL
Last Name:ITAWI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE M302
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-4890
Mailing Address - Fax:269-341-4889
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M302
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-4890
Practice Address - Fax:269-341-4889
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2023-11-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301084241208600000X, 390200000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1366645574Medicaid
MI1417961137OtherBCBS - BRONSON
MIC97618329 BRONSONMedicare PIN