Provider Demographics
NPI:1053674184
Name:JOEL DINVERNO MD PC
Entity Type:Organization
Organization Name:JOEL DINVERNO MD PC
Other - Org Name:SACRED HEART PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DINVERNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-522-6100
Mailing Address - Street 1:11755 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9219
Mailing Address - Country:US
Mailing Address - Phone:517-522-6100
Mailing Address - Fax:517-522-4715
Practice Address - Street 1:11755 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9219
Practice Address - Country:US
Practice Address - Phone:517-522-6100
Practice Address - Fax:517-522-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073676208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104717265Medicaid
MI3503810581OtherBCBS
MIG73511Medicare UPIN