Provider Demographics
NPI:1598947996
Name:ELLEN A. JANETZKE, M.D., P.C.
Entity Type:Organization
Organization Name:ELLEN A. JANETZKE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JANETZKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-258-5100
Mailing Address - Street 1:60 W BIG BEAVER RD STE 100NA
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3909
Mailing Address - Country:US
Mailing Address - Phone:248-258-5100
Mailing Address - Fax:248-258-5110
Practice Address - Street 1:60 W BIG BEAVER RD STE 100NA
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3909
Practice Address - Country:US
Practice Address - Phone:248-258-5100
Practice Address - Fax:248-258-5110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEJ066875174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P06660Medicare PIN