Provider Demographics
NPI:1427058957
Name:BLUNDEN, PAUL S (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:BLUNDEN
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 1:86 WILLOW TREE PL
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1322
Mailing Address - Country:US
Mailing Address - Phone:586-415-6200
Mailing Address - Fax:586-415-6217
Practice Address - Street 1:29751 LITTLE MACK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-2238
Practice Address - Country:US
Practice Address - Phone:586-415-6200
Practice Address - Fax:586-415-6217
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI406742174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E061676161OtherMEDICARE PROVIDER ID
MI2641140Medicaid
MI2641140Medicaid
MI0E061676161OtherMEDICARE PROVIDER ID