Provider Demographics
NPI:1942340187
Name:WALNUT LAKE OBGYN PLLC
Entity Type:Organization
Organization Name:WALNUT LAKE OBGYN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOLDSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-926-2020
Mailing Address - Street 1:2300 HAGGERTY RD
Mailing Address - Street 2:STE 2070
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2190
Mailing Address - Country:US
Mailing Address - Phone:248-926-2020
Mailing Address - Fax:248-926-9020
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:STE 2070
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-926-2020
Practice Address - Fax:248-926-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG035173207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1600F321780OtherBLUE CROSS GROUP PIN
MI1942340187OtherNPI
MI1942340187OtherNPI