Provider Demographics
NPI:1609870526
Name:STERN, EDWARD THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:THOMAS
Last Name:STERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2120 43RD ST SE
Mailing Address - Street 2:STE 700
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-3717
Mailing Address - Country:US
Mailing Address - Phone:616-455-6700
Mailing Address - Fax:616-455-7487
Practice Address - Street 1:2120 43RD ST SE
Practice Address - Street 2:STE 700
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-3717
Practice Address - Country:US
Practice Address - Phone:616-455-6700
Practice Address - Fax:616-455-7487
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039905207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2121032Medicaid
MI0411953Medicare ID - Type Unspecified
MIA77032Medicare UPIN