Provider Demographics
NPI:1780183186
Name:MD REGENERATION, PLLC
Entity Type:Organization
Organization Name:MD REGENERATION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-454-4916
Mailing Address - Street 1:41000 WOODWARD AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5092
Mailing Address - Country:US
Mailing Address - Phone:248-404-0501
Mailing Address - Fax:
Practice Address - Street 1:333 W 7TH ST STE 100
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2510
Practice Address - Country:US
Practice Address - Phone:248-561-0602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty