Healthcare Provider Details

I. General information

NPI: 1801854344
Provider Name (Legal Business Name): JOSE TAD-Y EDURESE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

DEPARTMENT 272801 PO BOX 67000
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4800
  • Fax:
Mailing address:
  • Phone: 517-782-9401
  • Fax: 517-784-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301032704
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: