Healthcare Provider Details

I. General information

NPI: 1114485703
Provider Name (Legal Business Name): JPS ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5302 GATEWAY CTR
FLINT MI
48507-3930
US

IV. Provider business mailing address

5302 GATEWAY CTR
FLINT MI
48507-3930
US

V. Phone/Fax

Practice location:
  • Phone: 248-396-8109
  • Fax:
Mailing address:
  • Phone: 248-396-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KYLE NIEPORTE
Title or Position: ADMIN
Credential:
Phone: 248-396-8109