=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700192424
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL LYNN LIDSTROM PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2010
-----------------------------------------------------
Last Update Date | 08/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 FORD PL SUITE 2E
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-3450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-937-3049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3139 S WAYNE RD
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48184-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-722-2722
-----------------------------------------------------
Fax | 734-722-7006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 5601002244
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------