Healthcare Provider Details

I. General information

NPI: 1376100073
Provider Name (Legal Business Name): IHA HEALTH SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S MAIN ST STE A
BROOKLYN MI
49230-9114
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: 517-592-8033
  • Fax: 517-592-3959
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA A ELLIOTT
Title or Position: PRESIDENT AND CHIEF OPERATING OFFIC
Credential:
Phone: 734-327-0872