Provider Demographics
NPI:1184620015
Name:HUTTNER, JEANINE S (MD)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:S
Last Name:HUTTNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 HARROUN RD
Mailing Address - Street 2:304
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2182
Mailing Address - Country:US
Mailing Address - Phone:419-824-1100
Mailing Address - Fax:419-824-1778
Practice Address - Street 1:5300 HARROUN RD
Practice Address - Street 2:304
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2182
Practice Address - Country:US
Practice Address - Phone:419-824-1100
Practice Address - Fax:419-824-1778
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA344428794OtherBEECH STREET
OH000000142498OtherANTHEM
MI6891OtherHEALTH PLAN OF MI
OH0855025Medicaid
OH4207270OtherAETNA
MI141887OtherCARE CHOICE
OH812OtherPARAMOUNT
OH344428794003OtherHUMANA/TRICARE
MI4115025Medicaid
OHOC03174OtherNATIONWIDE
OH344428794031OtherCARE SOURCES
OHE91991Medicare UPIN
OHOC03174OtherNATIONWIDE
MI141887OtherCARE CHOICE