MEDICARE: DR. CHARISE LANETTE VALENTINE M.D.

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	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	CV053752	MI
2	208D00000X	General Practice Physician	CV053752	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1306343272	OTHER	MI	BCBS PERSONAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	700H219440	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1366485039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARISE LANETTE VALENTINE M.D.

Provider Business Mailing Address
First Line	:	4245 S BEECH DALY ST
Second Line	:	SUITE 104
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-1567
Country	:	US
Telephone Number	:	313-730-9011
Fax Number	:	313-730-9013

Provider Business Practice Location Address
First Line	:	4245 S BEECH DALY ST
Second Line	:	SUITE 104
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-1567
Country	:	US
Telephone Number	:	313-730-9011
Fax Number	:	313-730-9013

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

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	02/04/2011

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Directions to “ DR. CHARISE LANETTE VALENTINE M.D.” Practice Location

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