Provider Demographics
NPI:1023281706
Name:JERRY NOSANCHUK DO PLLC
Entity type:Organization
Organization Name:JERRY NOSANCHUK DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOSANCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-926-8080
Mailing Address - Street 1:4545 NORTHRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1397
Mailing Address - Country:US
Mailing Address - Phone:248-926-8080
Mailing Address - Fax:248-926-8077
Practice Address - Street 1:31500 TELEGRAPH RD
Practice Address - Street 2:SUITE 210
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4367
Practice Address - Country:US
Practice Address - Phone:248-644-7200
Practice Address - Fax:248-644-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0158224424OtherBCBS MICHIGAN
MION38210Medicare PIN
MIE26132Medicare UPIN