Basic Information
| Provider Information | |||||||||
| NPI: | 1023045382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DY | ||||||||
| FirstName: | EDELWINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 274 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490362041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 358 E CHICAGO ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490362072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795252 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301058822 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3501243571 | 01 | MI | BCBS PIN | OTHER | 1231657 | 01 | MI | PHP/IBA | OTHER | 3243942 | 05 | MI | MEDICAID |