Healthcare Provider Details

I. General information

NPI: 1063628154
Provider Name (Legal Business Name): EDWARD JAMES MAUCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST DRH 3L-8, DEPT OF RADIOLOGY
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4415 FOX HILL DR
STERLING HEIGHTS MI
48310-3371
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-3430
  • Fax:
Mailing address:
  • Phone: 313-407-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301081864
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: