Provider Demographics
NPI:1679769061
Name:G SCOTT JENNING DO PC
Entity Type:Organization
Organization Name:G SCOTT JENNING DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:G
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-474-5456
Mailing Address - Street 1:28080 GRAND RIVER AVE
Mailing Address - Street 2:STE 208N
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5966
Mailing Address - Country:US
Mailing Address - Phone:248-478-7733
Mailing Address - Fax:248-478-3533
Practice Address - Street 1:28080 GRAND RIVER AVE
Practice Address - Street 2:STE 208N
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:248-478-7733
Practice Address - Fax:248-478-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007541208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1836048Medicaid