Provider Demographics
NPI:1952392599
Name:EDELSON, GARY W (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:EDELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:32255 NORTHWESTERN HWY STE 214
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1573
Mailing Address - Country:US
Mailing Address - Phone:248-855-5620
Mailing Address - Fax:248-855-5628
Practice Address - Street 1:32255 NORTHWESTERN HWY STE 214
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334
Practice Address - Country:US
Practice Address - Phone:248-855-5620
Practice Address - Fax:248-855-5628
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301054587207RE0101X
MI054587207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4138173Medicaid
MI4138173Medicaid
E95584Medicare UPIN