Healthcare Provider Details

I. General information

NPI: 1336349802
Provider Name (Legal Business Name): HEATHER WALTERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER WIDERHOLD MD

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 TELEGRAPH RD EMERGENCY MEDICINE DEPARTMENT
TAYLOR MI
48180-3330
US

IV. Provider business mailing address

38935 ANN ARBOR RD CREDENTIALING/PAYER CONTRACTING
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 313-295-5007
  • Fax: 313-295-6725
Mailing address:
  • Phone: 734-805-0477
  • Fax: 866-250-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301090081
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: