Basic Information
| Provider Information | |||||||||
| NPI: | 1003805318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDWELL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| 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 | ||||||||
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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 | 208G00000X | 071480 | MI | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 3423898 | 05 | MI | MEDICAID | CD7957 | 01 | MI | RAILROAD MEDICARE | OTHER | 3423904 | 05 | MI | MEDICAID | 4714890 | 05 | MI | MEDICAID | CD7959 | 01 | MI | RAILROAD MEDICARE | OTHER |