Provider Demographics
NPI:1922053537
Name:EDELMAN, BRIAN L (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:EDELMAN
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:PO BOX 55114
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48255
Mailing Address - Country:US
Mailing Address - Phone:248-858-3197
Mailing Address - Fax:248-858-3148
Practice Address - Street 1:461 WEST HURON STREET
Practice Address - Street 2:NORTH OAKLAND MEDICAL CENTER
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:248-857-7287
Practice Address - Fax:248-857-7051
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI077513207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00267382OtherRR MCR
MI4753870Medicaid
MIP00267382OtherRR MCR
MI4753870Medicaid