1962540419 NPI number — DR. JOHN ALEX JANSEN JR. MD

Table of content: DR. JOHN ALEX JANSEN JR. MD (NPI 1962540419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962540419 NPI number — DR. JOHN ALEX JANSEN JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANSEN
Provider First Name:
JOHN
Provider Middle Name:
ALEX
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1962540419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38935 ANN ARBOR RD
Provider Second Line Business Mailing Address:
CREDENTIALING/PAYOR CONTACTING
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48150-3397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-805-0487
Provider Business Mailing Address Fax Number:
866-250-6385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7300 N CANTON CENTER RD
Provider Second Line Business Practice Location Address:
EMERGENCY MEDICINE DEPARTMENT
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48187-1579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-454-8002
Provider Business Practice Location Address Fax Number:
866-250-6385
Provider Enumeration Date:
02/04/2007

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: 207P00000X , with the licence number:  4301045424 , 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: 1962540419 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com