Provider Demographics
NPI:1104918994
Name:TASHJIAN, EDWARD A (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:TASHJIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EDWARD
Other - Middle Name:A
Other - Last Name:TASHJIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3100 CROSS CREEK PKWY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-2774
Mailing Address - Country:US
Mailing Address - Phone:248-332-0296
Mailing Address - Fax:248-332-3466
Practice Address - Street 1:3100 CROSS CREEK PKWY
Practice Address - Street 2:SUITE 140
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2774
Practice Address - Country:US
Practice Address - Phone:248-332-0296
Practice Address - Fax:248-332-3466
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI046315174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2506321551OtherBCBSM
MI1347283Medicaid
MIA75899Medicare UPIN
MI0632155Medicare ID - Type UnspecifiedMEDICARE ID