Provider Demographics
NPI:1881881324
Name:PEDRAZA, EDGARD (MD)
Entity type:Individual
Prefix:
First Name:EDGARD
Middle Name:
Last Name:PEDRAZA
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 1:5528 METRO PKWY
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4105
Mailing Address - Country:US
Mailing Address - Phone:586-795-3232
Mailing Address - Fax:586-795-5540
Practice Address - Street 1:1547 S WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5436
Practice Address - Country:US
Practice Address - Phone:734-405-0176
Practice Address - Fax:586-795-5540
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010348952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N15280004OtherMEDICARE PIN LINKED TO APEX BEHAVIORAL HEALTH
MI4767490Medicaid
MI0N15280OtherMEDICARE GROUP ID FOR APEX BEHAVIORAL HEALTH
MI4308952 10Medicaid
MI0N15280004Medicare PIN
MIA79284Medicare UPIN
MI4767490Medicaid