MEDICARE: EDP OF MI II PC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1841785490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDP OF MI II PC

Provider Business Mailing Address
First Line	:	141 W JACKSON BLVD STE 210
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60604-3048
Country	:	US
Telephone Number	:	312-937-3619
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 NORTH AVE
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49017-3415
Country	:	US
Telephone Number	:	913-951-9644
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF INTEGRATIONS
Name	:	ROSEANNE BRUNENKANT
Credential	:
Telephone Number	:	312-937-3619

Provider Enumeration Date	:	06/26/2018
Last Update Date	:	09/16/2019

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