Provider Demographics
NPI:1649227315
Name:WADLE, RONA LITA (DO)
Entity Type:Individual
Prefix:DR
First Name:RONA
Middle Name:LITA
Last Name:WADLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 BIRD AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-2049
Mailing Address - Country:US
Mailing Address - Phone:248-644-4826
Mailing Address - Fax:
Practice Address - Street 1:33722 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-0912
Practice Address - Country:US
Practice Address - Phone:248-919-4900
Practice Address - Fax:248-919-4901
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013830207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114412960Medicaid
MI114412950Medicaid
MIRW013830OtherBC/BS OF MICHIGAN
MIH65468Medicare UPIN
MI114412950Medicaid
MIP48670001Medicare PIN