Provider Demographics
NPI:1376795559
Name:EDWARD, SELWAN O (MD)
Entity Type:Individual
Prefix:DR
First Name:SELWAN
Middle Name:O
Last Name:EDWARD
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 1:23300 ECORSE ROAD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-1768
Mailing Address - Country:US
Mailing Address - Phone:313-291-9500
Mailing Address - Fax:
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:INTERIM STAY UNIT OBSERVATION CARE
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-982-5770
Practice Address - Fax:313-982-5771
Is Sole Proprietor?:No
Enumeration Date:2008-10-19
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091975207RC0200X, 207R00000X
IN01081506A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
12290308OtherCAQH
MI1376795559Medicaid