Provider Demographics
NPI:1578558318
Name:SOOHOO-WILLIAMS, GAIL DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:DIANE
Last Name:SOOHOO-WILLIAMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43555 DALCOMA DR
Mailing Address - Street 2:STE 4
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6310
Mailing Address - Country:US
Mailing Address - Phone:586-228-2882
Mailing Address - Fax:586-463-7152
Practice Address - Street 1:43555 DALCOMA DR
Practice Address - Street 2:STE 4
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6310
Practice Address - Country:US
Practice Address - Phone:586-228-2882
Practice Address - Fax:586-463-7152
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407207208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E06114004OtherRAILROAD MEDICARE
MI1792650Medicaid
MI2505009741OtherBCN
MIC6825OtherM-CARE
MI119983OtherCARE CHOICES-PREFERRED
MIGS407207OtherBCBSM
MIE49886Medicare UPIN
MIOE06114Medicare ID - Type Unspecified