Basic Information
Provider Information
NPI: 1003802570
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RHAMES
FirstName: JODY
MiddleName: C
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 777 KIMOLE LN
Address2: SUITE 230
City: ADRIAN
State: MI
PostalCode: 492211478
CountryCode: US
TelephoneNumber: 5172635655
FaxNumber: 5172638012
Practice Location
Address1: 777 KIMOLE LN
Address2: SUITE 230
City: ADRIAN
State: MI
PostalCode: 492211478
CountryCode: US
TelephoneNumber: 5172635655
FaxNumber: 5172638012
Other Information
ProviderEnumerationDate: 09/21/2005
LastUpdateDate: 11/07/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X4301075052MIY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
00000037844201 ANTHEMOTHER
712103601 AETNAOTHER
12590201 CARECHOICES/PREFERRED CHOOTHER
080460168101 BCBS MIOTHER
P0025443401 RRMCOTHER
478356505MI MEDICAID


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