Provider Demographics
NPI:1790771475
Name:EDGE, JUDITH M (DO)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:EDGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1862
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:27015 W WARREN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1901
Practice Address - Country:US
Practice Address - Phone:313-278-1982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101009282207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3228454Medicaid
E80785Medicare UPIN
MI0Q26334026Medicare ID - Type Unspecified