MEDICARE: MARY PATRICIA BEDARD-LUSIS MD

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	208000000X	Pediatrics Physician	4301039853	MI
2	2080N0001X	Neonatal-Perinatal Medicine Physician	4301039853	MI

General Provider Information

NPI Number	:	1104863695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY PATRICIA BEDARD-LUSIS MD

Provider Business Mailing Address
First Line	:	4201 ST. ANTOINE UHC 6F MAILBOX# 226
Second Line	:	UNIVERSITY PEDIATRICIANS
City	:	DETROIT
State	:	MI
Zip	:	48201-2061
Country	:	US
Telephone Number	:	313-966-5051
Fax Number	:	313-966-6618

Provider Business Practice Location Address
First Line	:	CHILDRENS HOSPITAL MI NEONATOLOGY
Second Line	:	3901 BEAUBIEN 2ND FLOOR - MAIN BUILDING
City	:	DETROIT
State	:	MI
Zip	:	48201
Country	:	US
Telephone Number	:	313-745-1436
Fax Number	:

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	07/08/2010

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