Provider Demographics
NPI:1831190396
Name:UNDERHILL, JEANETTE ALLEN (MD)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ALLEN
Last Name:UNDERHILL
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:P.O. BOX 1468
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1468
Mailing Address - Country:US
Mailing Address - Phone:248-746-0342
Mailing Address - Fax:248-746-0308
Practice Address - Street 1:1620 MEDICAL LN STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1143
Practice Address - Country:US
Practice Address - Phone:239-275-1164
Practice Address - Fax:239-275-5212
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067713207ZP0102X
FLME130505207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI447790010Medicaid
MI0F36024016Medicare ID - Type Unspecified
MI447790010Medicaid