Basic Information
| Provider Information | |||||||||
| NPI: | 1104816081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDELSON | ||||||||
| FirstName: | ALICE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827070 | ||||||||
| FaxNumber: | 5865827066 | ||||||||
| Practice Location | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827070 | ||||||||
| FaxNumber: | 5865827066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 10/22/2008 | ||||||||
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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 | 207X00000X | 4301074428 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200E011770 | 01 | MI | BCBS GROUP NUMBER | OTHER | 4639122 | 05 | MI | MEDICAID |