Provider Demographics
NPI:1396947164
Name:JACALYN BISHOP, MD, PC
Entity type:Organization
Organization Name:JACALYN BISHOP, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACALYN
Authorized Official - Middle Name:MEREDITH
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:248-347-3344
Mailing Address - Street 1:44000 W 12 MILE ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377
Mailing Address - Country:US
Mailing Address - Phone:248-347-3344
Mailing Address - Fax:248-305-6845
Practice Address - Street 1:44000 W. 12 MILE RD,
Practice Address - Street 2:SUITE 103
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2646
Practice Address - Country:US
Practice Address - Phone:248-347-3344
Practice Address - Fax:348-305-6845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P47170Medicare PIN