Provider Demographics
NPI:1366533689
Name:ECCLES, EVELYN (MD)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:ECCLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 W MAIN ST
Mailing Address - Street 2:BOX 570
Mailing Address - City:MANCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48158-1002
Mailing Address - Country:US
Mailing Address - Phone:734-428-8381
Mailing Address - Fax:734-428-9066
Practice Address - Street 1:122 W MAIN ST
Practice Address - Street 2:BOX 570
Practice Address - City:MANCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48158-1002
Practice Address - Country:US
Practice Address - Phone:734-428-8381
Practice Address - Fax:734-428-9066
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0811119OtherBLUE CROSS/BLUE SHIELD
MI1802237Medicaid
MI0P45430Medicare PIN
MI0811119OtherBLUE CROSS/BLUE SHIELD