1457396251 NPI number — MELANIE JESSUP, DPM, PLLC

Table of content: DR. EUN HYE LEE MD (NPI 1912647231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457396251 NPI number — MELANIE JESSUP, DPM, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELANIE JESSUP, DPM, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457396251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20415 NORTHVILLE PLACE DR
Provider Second Line Business Mailing Address:
#2308
Provider Business Mailing Address City Name:
NORTHVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48167-2944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-596-1548
Provider Business Mailing Address Fax Number:
248-596-1548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20415 NORTHVILLE PLACE DR
Provider Second Line Business Practice Location Address:
#2308
Provider Business Practice Location Address City Name:
NORTHVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48167-2944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-596-1548
Provider Business Practice Location Address Fax Number:
248-596-1548
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JESSUP
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-596-1548

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  5901002083 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4853712 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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