Basic Information
| Provider Information | |||||||||
| NPI: | 1013145853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS-MOSURE | ||||||||
| FirstName: | KRISTAN | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENKINS | ||||||||
| OtherFirstName: | KRISTAN | ||||||||
| OtherMiddleName: | GAIL | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2213 CHERRY ST | ||||||||
| Address2: | ATTN: MRG ASSOCIATES, LLC - RADIOLOGY DEPT. | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436082603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192512740 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006536568 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 4301088572 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085B0100X | 35098978 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | 35098978 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 4301088572 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 35098978 | 01 | OH | OH MEDICAL LICENSE | OTHER | 0067438 | 05 | OH | MEDICAID |