Provider Demographics
NPI:1528045903
Name:WHITE, KERMIT E (MD)
Entity Type:Individual
Prefix:
First Name:KERMIT
Middle Name:E
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 1:28430 HERNDONWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334
Mailing Address - Country:US
Mailing Address - Phone:248-504-9723
Mailing Address - Fax:
Practice Address - Street 1:28430 HERNDONWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334
Practice Address - Country:US
Practice Address - Phone:248-504-9723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q0086502OtherSHO
IN200144090Medicaid
IN000000081497OtherANTHEM
IN000000081497OtherANTHEM
IN200144090Medicaid