Healthcare Provider Details

I. General information

NPI: 1235808494
Provider Name (Legal Business Name): IHA OLMA SPECIALTY 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19000 ST JOES PKWY STE 400
LIVONIA MI
48152-1477
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: 734-426-1931
  • Fax: 734-426-9021
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA A ELLIOTT
Title or Position: PRESIDENT
Credential:
Phone: 734-327-0872