Provider Demographics
NPI:1063579415
Name:BISHOP, JACALYN MEREDITH (MD)
Entity type:Individual
Prefix:DR
First Name:JACALYN
Middle Name:MEREDITH
Last Name:BISHOP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACALYN
Other - Middle Name:MEREDITH
Other - Last Name:LESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25500 MEADOWBROOK RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1878
Mailing Address - Country:US
Mailing Address - Phone:248-347-3344
Mailing Address - Fax:248-305-6845
Practice Address - Street 1:25500 MEADOWBROOK RD
Practice Address - Street 2:SUITE 130
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1878
Practice Address - Country:US
Practice Address - Phone:248-347-3344
Practice Address - Fax:248-305-6845
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010778932080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI519615310Medicaid