Healthcare Provider Details

I. General information

NPI: 1659082402
Provider Name (Legal Business Name): NORTHWEST PATHOLOGY CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 12/12/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44405 WOODWARD AVE
PONTIAC MI
48341-5023
US

IV. Provider business mailing address

PO BOX 670114
DETROIT MI
48267-0114
US

V. Phone/Fax

Practice location:
  • Phone: 989-459-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN EDELMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 248-858-3190