Healthcare Provider Details

I. General information

NPI: 1083651640
Provider Name (Legal Business Name): ANNA MARIE LEDGERWOOD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST STE 615
DETROIT MI
48201-2020
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400-CREDENTIALING
TROY MI
48083-1138
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4195
  • Fax: 313-993-8669
Mailing address:
  • Phone: 313-745-4195
  • Fax: 313-993-8669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301030780
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: