Provider Demographics
NPI:1164492500
Name:SITNER, JEROME (DO)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:SITNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4771 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48210-3247
Mailing Address - Country:US
Mailing Address - Phone:313-897-2600
Mailing Address - Fax:313-897-2424
Practice Address - Street 1:4771 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-3247
Practice Address - Country:US
Practice Address - Phone:313-897-2600
Practice Address - Fax:313-897-2424
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJS005168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381886254OtherCOMMERICAL NUMBERS
MI0P01030OtherMEDICARE GROUP NUMBER
MI1117984Medicaid
MI1164492500OtherNPI INDIVIDUAL
MIP0103003OtherMEDICARE INDIVIDUAL #S
MI0858218024OtherBCBS NUMBERS
MI1285813154OtherNPI # GROUP
MI0P01030OtherMEDICARE GROUP NUMBER
MI5821802Medicare ID - Type UnspecifiedMEDICARE NUMBERS