Basic Information
Provider Information
NPI: 1003805318
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CARDWELL
FirstName: ROBERT
MiddleName: J
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 25599 KELLY RD
Address2: SUITE A
City: ROSEVILLE
State: MI
PostalCode: 480664975
CountryCode: US
TelephoneNumber: 5867726000
FaxNumber: 5867727700
Practice Location
Address1: 25599 KELLY RD
Address2: SUITE A
City: ROSEVILLE
State: MI
PostalCode: 480664975
CountryCode: US
TelephoneNumber: 5867726000
FaxNumber: 5867727700
Other Information
ProviderEnumerationDate: 10/19/2005
LastUpdateDate: 04/20/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208G00000X071480MIY Allopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery) 

ID Information
IDTypeStateIssuerDescription
342390405MI MEDICAID
471489005MI MEDICAID
342389805MI MEDICAID
CD795701MIRAILROAD MEDICAREOTHER
CD795901MIRAILROAD MEDICAREOTHER


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