Provider Demographics
NPI:1932189958
Name:EBURUCHE, REGINALD N SR (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:N
Last Name:EBURUCHE
Suffix:SR
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 250077
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-0077
Mailing Address - Country:US
Mailing Address - Phone:313-549-5051
Mailing Address - Fax:248-440-6094
Practice Address - Street 1:26206 W 12 MILE RD
Practice Address - Street 2:STE 302
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8501
Practice Address - Country:US
Practice Address - Phone:248-440-6090
Practice Address - Fax:248-440-6094
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080385207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI470773210Medicaid
MI0P12430Medicare ID - Type Unspecified
MII26374Medicare UPIN