Provider Demographics
NPI:1659344562
Name:WEIDE, LORI (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WEIDE
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 1:7330 N CANTON CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7300 N CANTON CENTER RD
Practice Address - Street 2:SUITE 111
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1579
Practice Address - Country:US
Practice Address - Phone:734-454-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F22184Medicare UPIN