Provider Demographics
NPI:1588878201
Name:EBERT, CAROLYN L (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:L
Last Name:EBERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 S CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:CHESANING
Mailing Address - State:MI
Mailing Address - Zip Code:48616-1304
Mailing Address - Country:US
Mailing Address - Phone:989-845-7644
Mailing Address - Fax:989-845-4710
Practice Address - Street 1:300 S CHAPMAN ST
Practice Address - Street 2:
Practice Address - City:CHESANING
Practice Address - State:MI
Practice Address - Zip Code:48616-1304
Practice Address - Country:US
Practice Address - Phone:989-845-7644
Practice Address - Fax:989-845-4710
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588878201Medicaid
MIN53550070Medicare PIN