Provider Demographics
NPI:1316918519
Name:FONTANESI, JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:FONTANESI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27900 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5939
Mailing Address - Country:US
Mailing Address - Phone:248-477-0552
Mailing Address - Fax:248-477-0742
Practice Address - Street 1:27900 GRAND RIVER AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5939
Practice Address - Country:US
Practice Address - Phone:248-477-0552
Practice Address - Fax:248-477-0742
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301184432085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316918519Medicaid
MI700H273300OtherBLUE SHIELD
MI700H273300OtherBLUE SHIELD
B00140Medicare UPIN