Basic Information
| Provider Information | |||||||||
| NPI: | 1184636953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EBROM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 77000 | ||||||||
| Address2: | DEPT #77339 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482770339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163646700 | ||||||||
| FaxNumber: | 6163644960 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 JEFFERSON AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163646700 | ||||||||
| FaxNumber: | 6163644960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 08/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 4301044412 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4525177100 | 05 | MI | MEDICAID | P00009267 | 01 | MI | RR MEDICARE | OTHER |