Basic Information
| Provider Information | |||||||||
| NPI: | 1003004524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CISNEROS | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| 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 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 07/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 4301407270 | MI | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 204D00000X | 036-108497 | IL | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 2083X0100X | 4301407270 | MI | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700H231390 | 01 | MI | BCBSM GROUP NUMBER | OTHER |