Basic Information
| Provider Information | |||||||||
| NPI: | 1811374119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAMES | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZIPPLE | ||||||||
| OtherFirstName: | MONICA | ||||||||
| OtherMiddleName: | KAY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2220 WILLOW BEACH ST | ||||||||
| Address2: | |||||||||
| City: | KEEGO HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483201219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483387171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 44555 WOODWARD AVE STE 501 | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483415039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483387171 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2015 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208C00000X | 4301503536 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | IN PROGRESS | 05 | MI | MEDICAID |