Provider Demographics
NPI:1568529931
Name:NOSANCHUK, JERRY LEON (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEON
Last Name:NOSANCHUK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4545 NORTHRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1397
Mailing Address - Country:US
Mailing Address - Phone:248-926-8080
Mailing Address - Fax:248-926-8077
Practice Address - Street 1:31500 TELEGRAPH RD
Practice Address - Street 2:SUITE 210
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4367
Practice Address - Country:US
Practice Address - Phone:248-644-7200
Practice Address - Fax:248-644-7210
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101005933207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0158224424OtherBLUE CROSS BLUE SHIELD
MI0158224424OtherBLUE CROSS BLUE SHIELD
MIE26132Medicare UPIN