Provider Demographics
NPI:1174562524
Name:EDWARD M LICHTEN MD PC
Entity type:Organization
Organization Name:EDWARD M LICHTEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:LICHTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-593-9999
Mailing Address - Street 1:555 S OLD WOODWARD AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6658
Mailing Address - Country:US
Mailing Address - Phone:248-593-9999
Mailing Address - Fax:248-792-2997
Practice Address - Street 1:555 S OLD WOODWARD AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6658
Practice Address - Country:US
Practice Address - Phone:248-593-9999
Practice Address - Fax:248-792-2997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0636481Medicare ID - Type Unspecified