Provider Demographics
NPI:1679776264
Name:EVELYN ECCLES, MD
Entity Type:Organization
Organization Name:EVELYN ECCLES, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ECCLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-428-8381
Mailing Address - Street 1:122 W MAIN ST
Mailing Address - Street 2:BOX 570
Mailing Address - City:MANCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48158-1002
Mailing Address - Country:US
Mailing Address - Phone:734-428-8381
Mailing Address - Fax:734-428-9066
Practice Address - Street 1:122 W MAIN ST
Practice Address - Street 2:BOX 570
Practice Address - City:MANCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48158-1002
Practice Address - Country:US
Practice Address - Phone:734-428-8381
Practice Address - Fax:734-428-9066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-09
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1568521458OtherTAMAGNE PERSONAL NPI
MI1366533689OtherECCLES PERSONAL NPI
MI1802237Medicaid
MI1366533689OtherECCLES PERSONAL NPI
MID83181Medicare UPIN