Provider Demographics
NPI:1801854344
Name:EDURESE, JOSE TAD-Y (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:TAD-Y
Last Name:EDURESE
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:DEPARTMENT 272801
Mailing Address - Street 2:PO BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-782-9401
Mailing Address - Fax:517-784-2259
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-788-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101591571Medicaid
MI11023493OtherRR MEDICARE
MIN53130005Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL
MI11023493OtherRR MEDICARE