Provider Demographics
NPI:1710979638
Name:PAZUCHOWSKI, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:PAZUCHOWSKI
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:P.O. BOX 77000
Mailing Address - Street 2:DEPARTMENT 771036
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-1036
Mailing Address - Country:US
Mailing Address - Phone:586-447-4171
Mailing Address - Fax:586-447-4180
Practice Address - Street 1:29751 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-6503
Practice Address - Country:US
Practice Address - Phone:586-447-4100
Practice Address - Fax:586-447-4117
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3024768Medicaid
MI3024768Medicaid
MIM75620051Medicare ID - Type Unspecified