Provider Demographics
NPI:1568542082
Name:VANDERBILT, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:VANDERBILT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69011 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WHITE PIGEON
Mailing Address - State:MI
Mailing Address - Zip Code:49099-7727
Mailing Address - Country:US
Mailing Address - Phone:269-483-9991
Mailing Address - Fax:
Practice Address - Street 1:69011 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:WHITE PIGEON
Practice Address - State:MI
Practice Address - Zip Code:49099-7727
Practice Address - Country:US
Practice Address - Phone:269-483-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704211765363L00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1568542082Medicaid
MIMI1609006Medicare PIN
MI1568542082Medicaid