Provider Demographics
NPI:1780657478
Name:EDISON, MEGAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:EDISON
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 1:8485 ALGOMA AVE
Mailing Address - Street 2:C/O BROOKVILLE PEDIATRIC & INTERNAL MEDICINE, PC
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341
Mailing Address - Country:US
Mailing Address - Phone:616-243-5707
Mailing Address - Fax:616-243-1170
Practice Address - Street 1:1200 56TH ST SW
Practice Address - Street 2:C/O BROOKVILLE PEDIATRIC & INTERNAL MEDICINE, PC
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9704
Practice Address - Country:US
Practice Address - Phone:616-243-5707
Practice Address - Fax:616-243-1170
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086893208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11108809OtherCAQH #