Basic Information
| Provider Information | |||||||||
| NPI: | 1922121102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIN | ||||||||
| FirstName: | LI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3490 CALKINS RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107337741 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3490 CALKINS RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107337741 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247ZC0005X | 25MA06996600 | NJ | N | Technologists, Technicians & Other Technical Service Providers | Pathology | Clinical Laboratory Director, Non-physician | 207ZP0102X | 4301102186 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 1922121102 | 05 | MI | MEDICAID |