Provider Demographics
NPI:1912007998
Name:PINK, RITA JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RITA
Middle Name:JEAN
Last Name:PINK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7210 N MAIN ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-1575
Mailing Address - Country:US
Mailing Address - Phone:248-620-9199
Mailing Address - Fax:
Practice Address - Street 1:3010 TRENWEST DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3208
Practice Address - Country:US
Practice Address - Phone:336-718-5844
Practice Address - Fax:336-970-5298
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010499022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102389OtherGREAT LAKES HEALTH PLAN
MI2618606Medicaid
NC5905806Medicaid
MI1734905Medicaid
MI300020943OtherRAILROAD MEDICARE
MI1734923Medicaid
NC5905806Medicaid
NC2061667HMedicare PIN
MI1734923Medicaid
MIA77802Medicare UPIN
MI2618606Medicaid
NC2061667IMedicare PIN
NC2061667GMedicare PIN