MEDICARE: JACK HARRY PLOEGER RN

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	163WH0200X	Home Health Registered Nurse	4704301206	MI

General Provider Information

NPI Number	:	1265937544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK HARRY PLOEGER RN

Provider Business Mailing Address
First Line	:	1902 STAR BATT DR
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-3711
Country	:	US
Telephone Number	:	248-844-9650
Fax Number	:

Provider Business Practice Location Address
First Line	:	1902 STAR-BATT DRIVE
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-4830
Country	:	US
Telephone Number	:	248-844-9650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2018
Last Update Date	:	03/28/2018

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