Basic Information
Provider Information | |||||||||
NPI: | 1134129588 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLUNDEN | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | GAIL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | DEPARTMENT 771036 | ||||||||
Address2: | P.O. BOX 77000 | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482770001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864474171 | ||||||||
FaxNumber: | 5864474180 | ||||||||
Practice Location | |||||||||
Address1: | 21400 E 11 MILE RD | ||||||||
Address2: |   | ||||||||
City: | ST CLAIR SHORES | ||||||||
State: | MI | ||||||||
PostalCode: | 480811502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864984400 | ||||||||
FaxNumber: | 5864984440 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2005 | ||||||||
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 | 207V00000X | 4301059826 | MI | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 4599143-10 | 05 | MI |   | MEDICAID |