Provider Demographics
NPI:1396873402
Name:EDGEWOOD CENTER OTOLARYNGOLOGY, PC
Entity type:Organization
Organization Name:EDGEWOOD CENTER OTOLARYNGOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:YERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-360-5881
Mailing Address - Street 1:8898 COMMERCE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-4485
Mailing Address - Country:US
Mailing Address - Phone:248-360-5881
Mailing Address - Fax:248-360-5882
Practice Address - Street 1:8898 COMMERCE RD STE 1
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48382-4485
Practice Address - Country:US
Practice Address - Phone:248-360-5881
Practice Address - Fax:248-360-5882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHY055619207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0406389272OtherBCBS
P65910OtherBCN
MI3013138Medicaid
P65910OtherHAP
MI1396873402Medicare Oscar/Certification
MI1396873402Medicare NSC
E49601Medicare UPIN
MI3013138Medicaid