Basic Information
| Provider Information | |||||||||
| NPI: | 1962692483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3264 N EVERGREEN DR NE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163637339 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3264 N EVERGREEN DR NE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163637339 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 06/13/2016 | ||||||||
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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 | 2085R0202X | 5101017374 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 34010870 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 34010870 | 01 | OH | OHIO MEDICAL LICENSE | OTHER |