Provider Demographics
NPI:1447590971
Name:ERVIN, WILLIAM RYDALE
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:RYDALE
Last Name:ERVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22580 FRISBEE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1864
Mailing Address - Country:US
Mailing Address - Phone:248-469-5306
Mailing Address - Fax:
Practice Address - Street 1:24424 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3653
Practice Address - Country:US
Practice Address - Phone:313-531-2500
Practice Address - Fax:313-255-3465
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381917278Medicaid