Provider Demographics
NPI:1164559605
Name:JOEL L PELAVIN MD PC
Entity Type:Organization
Organization Name:JOEL L PELAVIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HALPIN
Authorized Official - Suffix:
Authorized Official - Credentials:C O A
Authorized Official - Phone:586-296-7770
Mailing Address - Street 1:29750 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-2607
Mailing Address - Country:US
Mailing Address - Phone:586-296-7770
Mailing Address - Fax:586-296-9617
Practice Address - Street 1:29750 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-2607
Practice Address - Country:US
Practice Address - Phone:586-296-7770
Practice Address - Fax:586-296-9617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJP042865332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJP042865OtherMEDICAL LICENSE NUMBER
MIJP042865OtherMEDICAL LICENSE NUMBER
MIB46179Medicare UPIN
MI0313400001Medicare NSC