Provider Demographics
NPI:1003895228
Name:MOURELATOS, JAN L (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:L
Last Name:MOURELATOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7272
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7272
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010528622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1006439OtherMCLAREN HEALTH
MI3513322Medicaid
OH26188036OtherFED BLACK LUNG PROGRAM
MI351332210OtherPROCARE
P00222749OtherRR MEDICARE/PALMETTO GBA
MI0H26188OtherBCBS PROVIDER NUMBER
0Q26008040OtherFED BLACK LUNG PROGRAM
MI111785OtherGREAT LAKES HEALTH
MI0Q26008OtherBCBS PROVIDER NUMBER
MIF57822Medicare UPIN