=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497314280
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN R BARTKUS PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2019
-----------------------------------------------------
Last Update Date | 06/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 HARRINGTON ST
-----------------------------------------------------
City | MOUNT CLEMENS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48043-2920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-493-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2170 CONNOLLY DR
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48098-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-740-4333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5601009472
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------