Provider Demographics
NPI:1750327904
Name:JACK, CHERYL BELLANCA (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:BELLANCA
Last Name:JACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:812 E JOLLY RD
Mailing Address - Street 2:STE 210
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6818
Mailing Address - Country:US
Mailing Address - Phone:517-346-8410
Mailing Address - Fax:517-346-8291
Practice Address - Street 1:812 E JOLLY RD
Practice Address - Street 2:STE G12
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6818
Practice Address - Country:US
Practice Address - Phone:517-346-8283
Practice Address - Fax:517-346-8291
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301062157208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF99601Medicare UPIN