Basic Information
Provider Information | |||||||||
NPI: | 1730527631 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OSBORNE | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | DONALD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | DEPT 771797 | ||||||||
Address2: | P O BOX 77000 | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482771797 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897995557 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5483 GRATIOT RD | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486386037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897995557 | ||||||||
FaxNumber: | 9894018240 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2013 | ||||||||
LastUpdateDate: | 03/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301103238 | MI | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | 4301103238 | MI | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.