Provider Demographics
NPI:1689668519
Name:KASLE, JEROME FITZGERALD (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:FITZGERALD
Last Name:KASLE
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 1:701 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3804
Mailing Address - Country:US
Mailing Address - Phone:810-238-3603
Mailing Address - Fax:810-767-5194
Practice Address - Street 1:701 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3804
Practice Address - Country:US
Practice Address - Phone:810-238-3603
Practice Address - Fax:810-767-5194
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029475174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5587790001OtherNATIONAL GOVERMENT SERVIC
MI4861868Medicaid
P25570002Medicare PIN
MIE38421Medicare UPIN