Basic Information
| Provider Information | |||||||||
| NPI: | 1891775730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KALLENBACH | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24681 NORTHWESTERN HWY | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480752305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483522000 | ||||||||
| FaxNumber: | 2483241477 | ||||||||
| Practice Location | |||||||||
| Address1: | 24681 NORTHWESTERN HWY | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480752305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483522000 | ||||||||
| FaxNumber: | 2483241477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 09/05/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301063038 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4403817 | 05 | MI | MEDICAID |