Provider Demographics
NPI:1588794523
Name:POU, EDGAR ALLAN (M,D)
Entity type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:ALLAN
Last Name:POU
Suffix:
Gender:M
Credentials:M,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 GRATIOT AVE
Mailing Address - Street 2:STE 2A
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-1200
Mailing Address - Country:US
Mailing Address - Phone:810-364-5050
Mailing Address - Fax:810-364-5688
Practice Address - Street 1:1985 GRATIOT BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2215
Practice Address - Country:US
Practice Address - Phone:810-364-5050
Practice Address - Fax:810-364-5688
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087010208D00000X, 207V00000X
PR12038207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR89080Medicare ID - Type Unspecified