Basic Information
| Provider Information | |||||||||
| NPI: | 1699712174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELDMAN | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | SUITE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138329324 | ||||||||
| FaxNumber: | 3139938685 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 BEAUBIEN ST FL 3 | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF MICHIGAN | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138329324 | ||||||||
| FaxNumber: | 3139938685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | 4301055642 | MI | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 207SG0202X | 4301055642 | MI | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Biochemical Genetics | 207SG0203X | 4301055642 | MI | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Molecular Genetics | 208000000X | 4301055642 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GF055642 | 01 | CHAMPUS-CHAMPUS | OTHER | 263022610 | 05 | MI | MEDICAID | GF055642 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | 700H262280 | 01 | BLUE CROSS-BLUE CROSS | OTHER |