Provider Demographics
NPI:1891796371
Name:EVERINGHAM, CRAIG J (DO)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:J
Last Name:EVERINGHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
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:947-522-1863
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:12100 S HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1119
Practice Address - Country:US
Practice Address - Phone:734-941-1070
Practice Address - Fax:734-941-1763
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI381898373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5820103OtherBLUE CROSS BLUE SHIELD
MI1290362 TYPE 11Medicaid
MI1891796371Medicare PIN
MI1290362 TYPE 11Medicaid