Provider Demographics
NPI:1902199862
Name:CHRISTOPHER IACOBELLI MD PC
Entity Type:Organization
Organization Name:CHRISTOPHER IACOBELLI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:IACOBELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-714-5100
Mailing Address - Street 1:14272 N FENTON RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1544
Mailing Address - Country:US
Mailing Address - Phone:810-714-5100
Mailing Address - Fax:810-714-5101
Practice Address - Street 1:14272 N FENTON RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1544
Practice Address - Country:US
Practice Address - Phone:810-714-5100
Practice Address - Fax:810-714-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-25
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty