Healthcare Provider Details

I. General information

NPI: 1952502213
Provider Name (Legal Business Name): LISA WHITEHEAD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WHITEHALL DR STE 230
ANN ARBOR MI
48105-9694
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR STE J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-769-3896
  • Fax: 734-769-3746
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0072297
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301115085
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: