1013145853 NPI number — KRISTAN GAIL JENKINS-MOSURE M.D.

Table of content: KRISTAN GAIL JENKINS-MOSURE M.D. (NPI 1013145853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013145853 NPI number — KRISTAN GAIL JENKINS-MOSURE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS-MOSURE
Provider First Name:
KRISTAN
Provider Middle Name:
GAIL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENKINS
Provider Other First Name:
KRISTAN
Provider Other Middle Name:
GAIL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013145853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2213 CHERRY ST
Provider Second Line Business Mailing Address:
ATTN: MRG ASSOCIATES, LLC - RADIOLOGY DEPT.
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43608-2603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-251-2740
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2799 W GRAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-653-6568
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2009

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: 2085B0100X , with the licence number:  4301088572 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085B0100X , with the licence number: 35098978 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 35098978 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 4301088572 , 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: 35098978 . This is a "OH MEDICAL LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0067438 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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