Basic Information
| Provider Information | |||||||||
| NPI: | 1114947959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RISE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37399 GARFIELD RD | ||||||||
| Address2: | STE 203 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480363672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862282911 | ||||||||
| FaxNumber: | 5862282901 | ||||||||
| Practice Location | |||||||||
| Address1: | 13355 E 10 MILE RD | ||||||||
| Address2: | SUITE 229 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480892048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867586263 | ||||||||
| FaxNumber: | 5867587725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 10/15/2019 | ||||||||
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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 | 207R00000X | 5101011870 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3263097 | 05 | MI | MEDICAID |