Basic Information
| Provider Information | |||||||||
| NPI: | 1710979638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAZUCHOWSKI | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 77000 | ||||||||
| Address2: | DEPARTMENT 771036 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482771036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864474171 | ||||||||
| FaxNumber: | 5864474180 | ||||||||
| Practice Location | |||||||||
| Address1: | 29751 LITTLE MACK AVE | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480666503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864474100 | ||||||||
| FaxNumber: | 5864474117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 02/15/2011 | ||||||||
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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 | 207Q00000X | 4301047752 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3024768 | 05 | MI | MEDICAID |