Basic Information
| Provider Information | |||||||||
| NPI: | 1669797494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOSE | ||||||||
| FirstName: | RANEEV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EPHREM | ||||||||
| OtherFirstName: | RANEEV | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 674147 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482674147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483544709 | ||||||||
| FaxNumber: | 2483544180 | ||||||||
| Practice Location | |||||||||
| Address1: | 26677 W 12 MILE RD # B6 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480341514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483544709 | ||||||||
| FaxNumber: | 2483544807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2010 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301090250 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1669797494 | 05 | MI | MEDICAID | 110F336360 | 01 | MI | BCBSM | OTHER | FJ1908815 | 01 | MI | DEA | OTHER | 4301090250 | 01 | MI | LICENSE | OTHER |