Healthcare Provider Details

I. General information

NPI: 1487903290
Provider Name (Legal Business Name): EMERGENCY DEPARTMENT PHYSICIANS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E 12 MILE RD
WARREN MI
48093-3472
US

IV. Provider business mailing address

17717 MASONIC
FRASER MI
48026-3158
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5000
  • Fax:
Mailing address:
  • Phone: 586-294-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY C. SOUTHALL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 586-294-0600