MEDICARE: DURENE M ELEM-VAUGHN DPM

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	213EP1101X	Primary Podiatric Medicine Podiatrist	5901001503	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4858252150	OTHER	MI	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417904376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DURENE M ELEM-VAUGHN DPM

Provider Business Mailing Address
First Line	:	1111 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-1802
Country	:	US
Telephone Number	:	313-386-0000
Fax Number	:	313-386-1597

Provider Business Practice Location Address
First Line	:	1111 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-1802
Country	:	US
Telephone Number	:	313-386-0000
Fax Number	:	313-386-1597

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

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	09/19/2008

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