Provider Demographics
NPI:1912052614
Name:FITZGERALD, EDMOND WILLIAM (M D)
Entity type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:WILLIAM
Last Name:FITZGERALD
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 1:4560 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3527
Mailing Address - Country:US
Mailing Address - Phone:810-385-4702
Mailing Address - Fax:810-966-3005
Practice Address - Street 1:2601 ELECTRIC AVE
Practice Address - Street 2:PHO OFFICE
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-987-1046
Practice Address - Fax:810-966-3005
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301022127207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine