Provider Demographics
NPI:1366485039
Name:VALENTINE, CHARISE LANETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARISE
Middle Name:LANETTE
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4245 S BEECH DALY ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-1567
Mailing Address - Country:US
Mailing Address - Phone:313-730-9011
Mailing Address - Fax:313-730-9013
Practice Address - Street 1:4245 S BEECH DALY ST
Practice Address - Street 2:SUITE 104
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125-1567
Practice Address - Country:US
Practice Address - Phone:313-730-9011
Practice Address - Fax:313-730-9013
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICV053752204D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1306343272OtherBCBS PERSONAL
MI4614876-10Medicaid
MI700H219440OtherBCBS
MI4614876-10Medicaid
MI700H219440OtherBCBS