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General NPI Number Information
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NPI Number | 1063528958
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Entity Type | Individual
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Provider Name | JEFFREY EDWIN MIDDELDORF D.O.
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Gender | Male
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Dates
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Enumeration Date | 08/22/2006
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Last Update Date | 12/10/2013
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Provider Practice Location Address
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Address Line | 5700 E 11 MILE ROAD SUITE C
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City | WARREN
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State | MI
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Zip | 48089
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Country | US
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Telephone | 586-558-4482
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Fax | 586-558-8923
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Provider Business Mailing Address
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Address Line | 888 WEST BIG BEAVER ROAD SUITE 480
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City | TROY
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State | MI
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Zip | 48084-4764
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Country | US
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Telephone | 248-797-8324
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Fax | 248-816-5173
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2301003007
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 5101012371
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 2238841
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License Number State | NY
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