Provider Demographics
NPI:1598784100
Name:JAIN, JITENDER KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:JITENDER
Middle Name:KUMAR
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25959 KELLY RD
Mailing Address - Street 2:STE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4991
Mailing Address - Country:US
Mailing Address - Phone:586-774-9010
Mailing Address - Fax:586-774-6758
Practice Address - Street 1:25959 KELLY RD
Practice Address - Street 2:STE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4991
Practice Address - Country:US
Practice Address - Phone:586-774-9010
Practice Address - Fax:586-774-6758
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIJJ033038207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2101890Medicaid
MI05017972OtherFEDERAL EMPLOYEE PLAN
MI830004296OtherRAILROAD MEDICARE
MI05017972OtherBLUE CROSS BLUE SHIELD
MI123770OtherTOTAL HEALTH PLAN
MI137717OtherCARE CHOICES
MI05017972OtherBLUE CROSS BLUE SHIELD
MI830004296OtherRAILROAD MEDICARE