Healthcare Provider Details

I. General information

NPI: 1699712174
Provider Name (Legal Business Name): GERALD L. FELDMAN MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 BEAUBIEN ST FL 3 CHILDREN'S HOSPITAL OF MICHIGAN
DETROIT MI
48201-2120
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-832-9324
  • Fax: 313-993-8685
Mailing address:
  • Phone: 313-832-9324
  • Fax: 313-993-8685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number4301055642
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License Number4301055642
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number4301055642
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301055642
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: