Healthcare Provider Details

I. General information

NPI: 1447749270
Provider Name (Legal Business Name): MERYL ELIZABETH ETHRIDGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15855 19 MILE RD
CLINTON TOWNSHIP MI
48038-3504
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-8030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number336126563
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301517811
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036171376
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: