Provider Demographics
NPI:1023223955
Name:HERBERT WEISENTHAL, D.O., P.L.L.C.
Entity Type:Organization
Organization Name:HERBERT WEISENTHAL, D.O., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-352-3790
Mailing Address - Street 1:29829 TELEGRAPH RD
Mailing Address - Street 2:SUITE L-102
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1330
Mailing Address - Country:US
Mailing Address - Phone:248-352-3790
Mailing Address - Fax:248-352-9712
Practice Address - Street 1:29829 TELEGRAPH RD
Practice Address - Street 2:SUITE L-102
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1330
Practice Address - Country:US
Practice Address - Phone:248-352-3790
Practice Address - Fax:248-352-9712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010056902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3102541Medicaid
MI3102541Medicaid