Provider Demographics
NPI:1265479430
Name:WHITE, BLAINE CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:CHARLES
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6245 DEACON HILL RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-7609
Mailing Address - Country:US
Mailing Address - Phone:517-546-2127
Mailing Address - Fax:
Practice Address - Street 1:6245 DEACON HILL RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-7609
Practice Address - Country:US
Practice Address - Phone:517-546-2127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031551207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101988685Medicaid
MIBW031551OtherBC/BS OF MICHIGAN
MI104715860Medicaid
MI104512750Medicaid
MI104512750Medicaid
MI104715860Medicaid