MEDICARE: JOEL DINVERNO MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	4301073676	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3503810581	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1053674184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOEL DINVERNO MD PC

Provider Business Mailing Address
First Line	:	11755 E MICHIGAN AVE
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9219
Country	:	US
Telephone Number	:	517-522-6100
Fax Number	:	517-522-4715

Provider Business Practice Location Address
First Line	:	11755 E MICHIGAN AVE
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9219
Country	:	US
Telephone Number	:	517-522-6100
Fax Number	:	517-522-4715

Authorized Official
Title or Position	:	OWNER
Name	:	JOEL DINVERNO
Credential	:	MD
Telephone Number	:	517-522-6100

Provider Enumeration Date	:	06/22/2012
Last Update Date	:	06/22/2012

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