Healthcare Provider Details

I. General information

NPI: 1346301645
Provider Name (Legal Business Name): ERNESTO HERMOSILLA BEDIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43565 ELIZABETH ST
MOUNT CLEMENS MI
48043-1034
US

IV. Provider business mailing address

809 PINE THISTLE LN
BLOOMFIELD HILLS MI
48302-2017
US

V. Phone/Fax

Practice location:
  • Phone: 586-307-9611
  • Fax:
Mailing address:
  • Phone: 248-646-1716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5315025174
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: