Provider Demographics
NPI:1841278645
Name:EDEN, ELIZABETH JEAN (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:JEAN
Last Name:EDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2755 CARPENTER RD
Practice Address - Street 2:SUITE 1S
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1186
Practice Address - Country:US
Practice Address - Phone:248-824-6622
Practice Address - Fax:248-324-1477
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301087321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR88020Medicare ID - Type Unspecified
G37252Medicare UPIN