=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699712174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD L. FELDMAN MD PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 05/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3950 BEAUBIEN ST FL 3 CHILDREN'S HOSPITAL OF MICHIGAN
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-832-9324
-----------------------------------------------------
Fax | 313-993-8685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1560 E MAPLE RD SUITE 400-CREDENTIALING
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48083-1189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-832-9324
-----------------------------------------------------
Fax | 313-993-8685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207SG0201X
-----------------------------------------------------
Taxonomy Name | Clinical Genetics (M.D.) Physician
-----------------------------------------------------
License Number | 4301055642
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207SG0202X
-----------------------------------------------------
Taxonomy Name | Clinical Biochemical Genetics Physician
-----------------------------------------------------
License Number | 4301055642
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207SG0203X
-----------------------------------------------------
Taxonomy Name | Clinical Molecular Genetics Physician
-----------------------------------------------------
License Number | 4301055642
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301055642
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------