Healthcare Provider Details

I. General information

NPI: 1104860030
Provider Name (Legal Business Name): JESUS HERNANDEZ JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W 6TH ST
CLARE MI
48617-1409
US

IV. Provider business mailing address

2000 GREEN RD SUITE 300
ANN ARBOR MI
48105-1598
US

V. Phone/Fax

Practice location:
  • Phone: 989-386-9951
  • Fax:
Mailing address:
  • Phone: 734-995-3764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number048887
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: