Provider Demographics
NPI:1700861366
Name:PELAVIN, RONALD D (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:D
Last Name:PELAVIN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:28625 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 243
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1828
Mailing Address - Country:US
Mailing Address - Phone:248-358-2310
Mailing Address - Fax:248-352-0734
Practice Address - Street 1:28625 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 243
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1828
Practice Address - Country:US
Practice Address - Phone:248-358-2310
Practice Address - Fax:248-352-0734
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301038316207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0632560OtherBCBS INDIVIDUAL
MI1700861366Medicaid
MI110202017OtherRR MEDICARE
MI700F314390OtherBLUE SHIELD
MI1700861366Medicaid
MI0M96210003Medicare PIN