MEDICARE: DR. EDMOND J. DUCOMMUN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	4301059003	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00464732	OTHER	MI	RAILROAD MEDICARE
9	0M214400029	OTHER	MI	MEDICARE PLUS BLUE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200000001909	OTHER	MI	PHP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	4594007	OTHER	MI	AETNA
5	200000001909	OTHER	MI	PHP FAMILYCARE
6	0250331789	OTHER	MI	BLUE CROSS BLUE SHIELD OF MICHIGAN
7	1010729	OTHER	MI	MCLAREN HEALTH PLAN-COMMERCIAL
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	1010729	OTHER	MI	MCLAREN HEALTH ADVANTAGE
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093767816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDMOND J. DUCOMMUN M.D.

Provider Business Mailing Address
First Line	:	1540 LAKE LANSING RD
Second Line	:	STE 101
City	:	LANSING
State	:	MI
Zip	:	48912-3707
Country	:	US
Telephone Number	:	517-913-3810
Fax Number	:	517-913-3811

Provider Business Practice Location Address
First Line	:	1540 LAKE LANSING RD
Second Line	:	STE 101
City	:	LANSING
State	:	MI
Zip	:	48912-3707
Country	:	US
Telephone Number	:	517-913-3810
Fax Number	:	517-913-3811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	09/03/2019

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