Healthcare Provider Details

I. General information

NPI: 1508484510
Provider Name (Legal Business Name): MR. EDWARD A GARDIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 LEDYARD ST
DETROIT MI
48201
US

IV. Provider business mailing address

445 LEDYARD ST
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-962-9446
  • Fax: 313-962-6395
Mailing address:
  • Phone: 313-962-9446
  • Fax: 313-962-6395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: