Healthcare Provider Details

I. General information

NPI: 1255508487
Provider Name (Legal Business Name): EDWIN ROBERT ITENBERG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD FISHER BUILDING 3RD FLOOR
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

16001 W 9 MILE RD FISHER BUILDING 3RD FLOOR
SOUTHFIELD MI
48075-4818
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-6030
  • Fax: 248-849-6039
Mailing address:
  • Phone: 248-849-6030
  • Fax: 248-849-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number5101019112
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101019112
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: