Provider Demographics
NPI:1497740781
Name:JARDINE, MICHELLE CECELIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:CECELIA
Last Name:JARDINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:421 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2313
Mailing Address - Country:US
Mailing Address - Phone:631-941-1000
Mailing Address - Fax:631-941-1010
Practice Address - Street 1:213 HALLOCK RD
Practice Address - Street 2:SUITE 6
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3000
Practice Address - Country:US
Practice Address - Phone:631-941-1000
Practice Address - Fax:631-941-1010
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY207582207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH23134Medicare UPIN