Basic Information
| Provider Information | |||||||||
| NPI: | 1588740690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | JERROLD | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3955 PATIENT CARE WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173747600 | ||||||||
| FaxNumber: | 5173749042 | ||||||||
| Practice Location | |||||||||
| Address1: | 3955 PATIENT CARE WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173747600 | ||||||||
| FaxNumber: | 5173749042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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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 | 2085B0100X | 4301033414 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0904X | 4301033414 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085U0001X | 4301033414 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 4301033414 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.