Basic Information
Provider Information
NPI: 1003004524
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CISNEROS
FirstName: CHRISTINE
MiddleName: MARIE
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2760 EMBER WAY
Address2:  
City: ANN ARBOR
State: MI
PostalCode: 481046462
CountryCode: US
TelephoneNumber: 7349130949
FaxNumber:  
Practice Location
Address1: 700 E BEARDSLEY AVE
Address2: STE 100
City: ELKHART
State: IN
PostalCode: 465143366
CountryCode: US
TelephoneNumber: 5742068010
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/10/2007
LastUpdateDate: 07/29/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
204D00000X036-108497ILN Allopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM 
204D00000X4301407270MIN Allopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM 
2083X0100X4301407270MIY Allopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine

ID Information
IDTypeStateIssuerDescription
700H23139001MIBCBSM GROUP NUMBEROTHER


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