Basic Information
| Provider Information | |||||||||
| NPI: | 1114975745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERNICONE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173534911 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 SERVICE ROAD | ||||||||
| Address2: | ROOM A204 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173534920 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5101007728 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2900608 | 05 | MI | MEDICAID | 1114975745 | 05 | MI | MEDICAID |