NPIMap

Individual provider Active NPI

Jack Trebelhorn, MD

  • Urology Physician
  • Saint Clair Shores, MI
National Provider Identifier
1619331998
Registry record updated Jun 9, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urology PhysicianTaxonomy code 208800000X
License
DR.0067578 Issued in CO
Practice address
20952 E 12 Mile Rd Ste 200
Saint Clair Shores, MI 48081-3203
Phone
(586) 771-4820
Fax
(303) 485-3377
NPI assigned
Apr 12, 2016
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Urology Physician 208800000X DR.0067578 CO Primary

Addresses

Primary practice location

20952 E 12 Mile Rd Ste 200
Saint Clair Shores, MI 48081-3203

Mailing address

20952 E 12 Mile Rd Ste 200
Saint Clair Shores, MI 48081-3203
Phone (586) 771-4820

Other identifiers 1

IdentifierTypeStateIssuer
1619331998MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20220610002496 MI Practitioner - Urology 6800180050 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Urology
Education
Medical College of Wisconsin, 2016
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Michigan Institute of Urology PCGroup PAC ID 1052223492, 82 clinicians

Practice addresses (Care Compare)

20952 E 12 Mile Rd
Suite 200
Saint Clair Shores, MI 48081-3203
Phone (586) 771-4820

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
100 of 100Reported as individual
Promoting interoperability
98
Improvement activities
40

Procedures performed for Medicare patients

ProcedureNumber of procedures
Prostate resection1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Alliance Physician Services of Michigan, P.C. Urology CurrentSince Jul 1, 2022 Accepting new patients
Michigan Institute of Urology PC Urology CurrentSince Jul 1, 2022 Accepting new patients

Locations

22101 Moross Rd
Detroit, MI 48236
Phone (313) 343-3248

20952 E 12 Mile Rd
Ste 200
St Clr Shores, MI 48081
Phone (586) 771-4820

Interoperability endpoints

  • Direct secure messaging: jtrebelhorn1155908@direct.hfhs.org

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1460419200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1654732800000",
    "number": "1619331998",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20952 E 12 MILE RD STE 200",
            "city": "SAINT CLAIR SHORES",
            "state": "MI",
            "postal_code": "480813203",
            "telephone_number": "586-771-4820",
            "fax_number": "303-485-3377"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20952 E 12 MILE RD STE 200",
            "city": "SAINT CLAIR SHORES",
            "state": "MI",
            "postal_code": "480813203",
            "telephone_number": "586-771-4820",
            "fax_number": "303-485-3377"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TREBELHORN",
        "first_name": "JACK",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-04-12",
        "last_updated": "2022-06-09",
        "certification_date": "2022-06-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": "CO",
            "license": "DR.0067578",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1619331998",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Clair Shores, MI

Sources for this page

Verify at the official NPI Registry.