Provider Demographics
NPI:1740234236
Name:WHITE PINE FAMILY MEDICINE
Entity Type:Organization
Organization Name:WHITE PINE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:RT(R)
Authorized Official - Phone:6916-696-2020
Mailing Address - Street 1:261 N MAIN
Mailing Address - Street 2:PO BOX 221K
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-9709
Mailing Address - Country:US
Mailing Address - Phone:616-696-2020
Mailing Address - Fax:616-696-4860
Practice Address - Street 1:261 N MAIN
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-9709
Practice Address - Country:US
Practice Address - Phone:616-696-2020
Practice Address - Fax:616-696-4860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4737787Medicaid
MI4737787Medicaid