1093872178 NPI number — MRS. JESSICA MICHELLE SIEWERT RD CDE

Table of content: MRS. JESSICA MICHELLE SIEWERT RD CDE (NPI 1093872178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093872178 NPI number — MRS. JESSICA MICHELLE SIEWERT RD CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIEWERT
Provider First Name:
JESSICA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LETARTE
Provider Other First Name:
JESSICA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093872178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12115 BARBARA ANN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48095-1428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-623-3067
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44250 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
OUTPATIENT DIABETES EDUCATION, 2ND FLOOR
Provider Business Practice Location Address City Name:
STERLING HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48314-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-964-0359
Provider Business Practice Location Address Fax Number:
248-964-8050
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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