Healthcare Provider Details

I. General information

NPI: 1366533689
Provider Name (Legal Business Name): EVELYN ECCLES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W MAIN ST BOX 570
MANCHESTER MI
48158-1002
US

IV. Provider business mailing address

122 W MAIN ST BOX 570
MANCHESTER MI
48158-1002
US

V. Phone/Fax

Practice location:
  • Phone: 734-428-8381
  • Fax: 734-428-9066
Mailing address:
  • Phone: 734-428-8381
  • Fax: 734-428-9066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301043902
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: