Provider Demographics
NPI:1114363108
Name:JOHN R. WHITTAKER, M.D., PLLC
Entity Type:Organization
Organization Name:JOHN R. WHITTAKER, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:WHITTAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-423-0903
Mailing Address - Street 1:6431 BAUERVIC BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2237
Mailing Address - Country:US
Mailing Address - Phone:248-851-0635
Mailing Address - Fax:248-851-6463
Practice Address - Street 1:20240 W 12 MILE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2426
Practice Address - Country:US
Practice Address - Phone:248-423-0903
Practice Address - Fax:248-423-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039465208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2120509Medicaid
MIA73848Medicare UPIN
MI0630614Medicare PIN