Basic Information
| Provider Information | |||||||||
| NPI: | 1831190396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UNDERHILL | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1468 | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480991468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487460342 | ||||||||
| FaxNumber: | 2487460308 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 MEDICAL LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392751164 | ||||||||
| FaxNumber: | 2392755212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 4301067713 | MI | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | ME130505 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 447790010 | 05 | MI | MEDICAID |