Healthcare Provider Details

I. General information

NPI: 1164492500
Provider Name (Legal Business Name): JEROME SITNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4771 MICHIGAN AVE
DETROIT MI
48210-3247
US

IV. Provider business mailing address

4771 MICHIGAN AVE
DETROIT MI
48210-3247
US

V. Phone/Fax

Practice location:
  • Phone: 313-897-2600
  • Fax: 313-897-2424
Mailing address:
  • Phone: 313-897-2600
  • Fax: 313-897-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJS005168
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: