Healthcare Provider Details

I. General information

NPI: 1730177783
Provider Name (Legal Business Name): JAMES L WEATHERHEAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 W GREEN ST SUITE G100
HASTINGS MI
49058-1712
US

IV. Provider business mailing address

1005 W GREEN ST SUITE G100
HASTINGS MI
49058-1712
US

V. Phone/Fax

Practice location:
  • Phone: 269-948-7820
  • Fax: 269-948-2458
Mailing address:
  • Phone: 269-948-7820
  • Fax: 269-948-2458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301032093
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: