Basic Information
| Provider Information | |||||||||
| NPI: | 1164846929 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NELLI MEDICAL SERVICES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5827 CALGARY CT | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483143070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487594852 | ||||||||
| FaxNumber: | 2482999860 | ||||||||
| Practice Location | |||||||||
| Address1: | 1349 S ROCHESTER RD | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483073150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487594852 | ||||||||
| FaxNumber: | 2482999860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2014 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOSE | ||||||||
| AuthorizedOfficialFirstName: | JINSON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2482999850 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 4301085938 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 4301085938 | 01 | MI | STATE LICENSE | OTHER | FJ1893773 | 01 | MI | DEA | OTHER | 5315044008 | 01 | MI | CDS | OTHER |