Provider Demographics
NPI:1790901304
Name:WHITMORE LAKE HEALTH CLINIC
Entity Type:Organization
Organization Name:WHITMORE LAKE HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-449-2033
Mailing Address - Street 1:9690 E MI STATE ROAD 36
Mailing Address - Street 2:PO BOX 606
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9703
Mailing Address - Country:US
Mailing Address - Phone:734-449-2033
Mailing Address - Fax:734-449-7186
Practice Address - Street 1:9690 E MI STATE ROAD 36
Practice Address - Street 2:
Practice Address - City:WHITMORE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48189-9703
Practice Address - Country:US
Practice Address - Phone:734-449-2033
Practice Address - Fax:734-449-7186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty