Healthcare Provider Details

I. General information

NPI: 1720376718
Provider Name (Legal Business Name): JEREMY LOTT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27351 DEQUINDRE RD
MADISON HEIGHTS MI
48071
US

IV. Provider business mailing address

27351 DEQUINDRE RD
MADISON HEIGHTS MI
48071-3487
US

V. Phone/Fax

Practice location:
  • Phone: 248-967-7795
  • Fax: 248-967-7794
Mailing address:
  • Phone: 248-967-7795
  • Fax: 248-967-7794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101019558
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2928-321
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036145520
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: