Provider Demographics
NPI:1376565994
Name:BELEN, JACK G (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:BELEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:20307 WEST 12 MILE ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20307 WEST 12 MILE ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:248-356-6661
Practice Address - Fax:248-356-6619
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIJB042374208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1552582Medicaid
MI1552582Medicaid
B49014Medicare UPIN