Provider Demographics
NPI:1992285118
Name:JAN MEDICAL INC
Entity type:Organization
Organization Name:JAN MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUDLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-921-5593
Mailing Address - Street 1:45686 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3919
Mailing Address - Country:US
Mailing Address - Phone:248-921-5593
Mailing Address - Fax:
Practice Address - Street 1:45686 S LAKE DR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3919
Practice Address - Country:US
Practice Address - Phone:248-921-5593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164477816Medicaid