Provider Demographics
NPI:1215905765
Name:FORDYCE, JAMES G (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:FORDYCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19855 OUTER DR
Mailing Address - Street 2:STE 204
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2022
Mailing Address - Country:US
Mailing Address - Phone:313-565-3565
Mailing Address - Fax:313-565-7723
Practice Address - Street 1:19855 OUTER DR
Practice Address - Street 2:STE 204
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2022
Practice Address - Country:US
Practice Address - Phone:313-565-3565
Practice Address - Fax:313-565-7723
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034472207KI0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H26340OtherBLUE CROSS
MI1290003Medicaid
MIB46304Medicare UPIN
MI0H26340Medicare ID - Type Unspecified