Healthcare Provider Details

I. General information

NPI: 1134283633
Provider Name (Legal Business Name): WASHTENAW UROLOGY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 BURR STREET
JACKSON MI
49201
US

IV. Provider business mailing address

1010 BURR STREET
JACKSON MI
49201
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-7474
  • Fax: 517-782-2128
Mailing address:
  • Phone: 517-782-7474
  • Fax: 517-782-2128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberJS056395
License Number StateMI

VIII. Authorized Official

Name: DR. JONATHAN P SYKES
Title or Position: PRESIDENT
Credential: MD
Phone: 517-782-7474