Basic Information
| Provider Information | |||||||||
| NPI: | 1447297742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACDONALD | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD | ||||||||
| Address2: | A201 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W GREENLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489102819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179759500 | ||||||||
| FaxNumber: | 5179759511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 4301053125 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1447297742 | 05 | MI | MEDICAID | 01004511 | 01 | MI | HEALTHPLUS | OTHER | 1014282 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 4711898-10 | 05 | MI | MEDICAID | 4711403-10 | 05 | MI | MEDICAID | 1102911631 | 01 | MI | BCBSM | OTHER | 200000005798 | 01 | MI | PHP COMMERCIAL | OTHER | 4711913-10 | 05 | MI | MEDICAID |