Provider Demographics
NPI:1619266442
Name:SOUTH LYON FAMILY DOCS PC
Entity Type:Organization
Organization Name:SOUTH LYON FAMILY DOCS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:EBERHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-437-5613
Mailing Address - Street 1:26006 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-8050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26006 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-8050
Practice Address - Country:US
Practice Address - Phone:248-437-5613
Practice Address - Fax:248-437-5694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty