Healthcare Provider Details

I. General information

NPI: 1265937544
Provider Name (Legal Business Name): JACK HARRY PLOEGER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 STAR-BATT DRIVE
ROCHESTER HILLS MI
48309-4830
US

IV. Provider business mailing address

1902 STAR BATT DR
ROCHESTER HILLS MI
48309-3711
US

V. Phone/Fax

Practice location:
  • Phone: 248-844-9650
  • Fax:
Mailing address:
  • Phone: 248-844-9650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704301206
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: