Healthcare Provider Details

I. General information

NPI: 1134129588
Provider Name (Legal Business Name): ELIZABETH GAIL BLUNDEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16815 E JEFFERSON AVE STE 120
GROSSE POINTE MI
48230-1923
US

IV. Provider business mailing address

DEPARTMENT 771036 P.O. BOX 77000
DETROIT MI
48277-0001
US

V. Phone/Fax

Practice location:
  • Phone: 586-498-4400
  • Fax: 586-498-4440
Mailing address:
  • Phone: 586-447-4171
  • Fax: 586-447-4180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301059826
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: