Provider Demographics
NPI:1285819383
Name:PENROSE, ALICE STEVENS (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:STEVENS
Last Name:PENROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3174 PACKARD ROAD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1947
Mailing Address - Country:US
Mailing Address - Phone:734-971-1073
Mailing Address - Fax:734-929-9911
Practice Address - Street 1:3174 PACKARD ROAD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1947
Practice Address - Country:US
Practice Address - Phone:734-971-1073
Practice Address - Fax:734-929-9911
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F08824Medicare UPIN