Provider Demographics
NPI:1235120742
Name:JANETZKE, ELLEN AMANDA (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:AMANDA
Last Name:JANETZKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W BIG BEAVER RD
Mailing Address - Street 2:STE 100
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3913
Mailing Address - Country:US
Mailing Address - Phone:248-258-5100
Mailing Address - Fax:
Practice Address - Street 1:60 W BIG BEAVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3913
Practice Address - Country:US
Practice Address - Phone:248-258-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066875174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4427695Medicaid
MI0634039OtherBLUE CROSS BLUE SHIELD
MI7316280OtherAETNA
MIP06660001Medicare PIN
MI7316280OtherAETNA