Healthcare Provider Details

I. General information

NPI: 1619266442
Provider Name (Legal Business Name): SOUTH LYON FAMILY DOCS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26006 PONTIAC TRL
SOUTH LYON MI
48178-8050
US

IV. Provider business mailing address

26006 PONTIAC TRL
SOUTH LYON MI
48178-8050
US

V. Phone/Fax

Practice location:
  • Phone: 248-437-5613
  • Fax: 248-437-5694
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101016493
License Number StateMI

VIII. Authorized Official

Name: BRANDY EBERHARDT
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 248-437-5613