Provider Demographics
NPI:1114975745
Name:PERNICONE, JOSEPH R (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
Last Name:PERNICONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-975-8930
Mailing Address - Fax:517-337-4985
Practice Address - Street 1:3220 DISCOVERY DR STE 100
Practice Address - Street 2:ROOM A204
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8556
Practice Address - Country:US
Practice Address - Phone:517-975-8930
Practice Address - Fax:517-337-4985
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010077282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114975745Medicaid
MI2900608Medicaid
MI2900608Medicaid
MIC36350012Medicare ID - Type Unspecified