Provider Demographics
NPI:1093101537
Name:WHITE, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15414 HUBBELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2968
Mailing Address - Country:US
Mailing Address - Phone:313-575-0735
Mailing Address - Fax:
Practice Address - Street 1:15414 HUBBELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2968
Practice Address - Country:US
Practice Address - Phone:313-575-0735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-11
Last Update Date:2015-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9287256251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9287256OtherDEPARTMENT OF HUMAN RESOURCES