Basic Information
| Provider Information | |||||||||
| NPI: | 1316918519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTANESI | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 27900 GRAND RIVER AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483365939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484770552 | ||||||||
| FaxNumber: | 2484770742 | ||||||||
| Practice Location | |||||||||
| Address1: | 27900 GRAND RIVER AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483365939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484770552 | ||||||||
| FaxNumber: | 2484770742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 05/24/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 430118443 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1316918519 | 05 | MI | MEDICAID | 700H273300 | 01 | MI | BLUE SHIELD | OTHER |