Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 4301039853 | MI |
Y | 2080N0001X | Neonatal-Perinatal Doctor | 4301039853 | MI |
NPI | 1104863695 |
---|---|
Provider Name | Mary Patricia Bedard-Lusis |
First Address | Detroit, MI 48201-2061 |
Second Address | Detroit, MI 48201 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2006 |
Last Update Date | 08/07/2010 |