Provider Demographics
NPI:1811149115
Name:PIWOWARSKI, JENNIFER MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:PIWOWARSKI
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 1:3782 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5337
Mailing Address - Country:US
Mailing Address - Phone:231-935-6080
Mailing Address - Fax:231-935-6081
Practice Address - Street 1:7985 MACKINAW TRL
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8111
Practice Address - Country:US
Practice Address - Phone:231-876-6200
Practice Address - Fax:231-876-6299
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090555207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238635Medicare Oscar/Certification