Provider Demographics
NPI:1306043039
Name:J T AILLS MD PC
Entity Type:Organization
Organization Name:J T AILLS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:T
Authorized Official - Last Name:AILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-230-7905
Mailing Address - Street 1:4448 OAKBRIDGE DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-5484
Mailing Address - Country:US
Mailing Address - Phone:810-230-7905
Mailing Address - Fax:810-230-7908
Practice Address - Street 1:4448 OAKBRIDGE DR STE A
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5484
Practice Address - Country:US
Practice Address - Phone:810-230-7905
Practice Address - Fax:810-230-7908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJA0339882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1498263Medicaid
MI0P10330Medicare ID - Type Unspecified
MI1498263Medicaid