Provider Demographics
NPI:1275514721
Name:LABINE, JAY PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:PATRICK
Last Name:LABINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 CHERRY ST SE STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4607
Mailing Address - Country:US
Mailing Address - Phone:616-456-5311
Mailing Address - Fax:616-456-7955
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-456-5311
Practice Address - Fax:616-456-7955
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058128208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16117OtherBCBS
MI3352544Medicaid
MI3352544Medicaid
MI0D16117003Medicare PIN