Basic Information
| Provider Information | |||||||||
| NPI: | 1366480485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERES | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FORD PL | ||||||||
| Address2: | 2E | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744806 | ||||||||
| FaxNumber: | 3138744677 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006536568 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 01/23/2014 | ||||||||
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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 | 207R00000X | 4301071038 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 4301071038 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | 4301071038 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4941691 | 05 | MI | MEDICAID |