Provider Demographics
NPI:1780643643
Name:EDMOND, ELIZABETH W (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:W
Last Name:EDMOND
Suffix:
Gender:F
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:PO BOX 914
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48303-0914
Mailing Address - Country:US
Mailing Address - Phone:313-430-3775
Mailing Address - Fax:
Practice Address - Street 1:4700 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3698
Practice Address - Country:US
Practice Address - Phone:313-581-2600
Practice Address - Fax:313-581-0228
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEE028998208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1957974Medicaid
MI250H222820OtherBCBSM
MI250H222820OtherBCBSM
MI1822455Medicare ID - Type Unspecified