Healthcare Provider Details

I. General information

NPI: 1790901072
Provider Name (Legal Business Name): GARY HOLLANDER DO PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N PONTIAC TRL
WALLED LAKE MI
48390-3443
US

IV. Provider business mailing address

620 N PONTIAC TRL
WALLED LAKE MI
48390-3443
US

V. Phone/Fax

Practice location:
  • Phone: 248-624-4511
  • Fax: 248-624-4408
Mailing address:
  • Phone: 248-624-4511
  • Fax: 248-624-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number5101013058
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number5101012793
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002389
License Number StateMI

VIII. Authorized Official

Name: MRS. DEBBIE SUE WITT-HAGGERTY
Title or Position: OFFICE MANAGER
Credential:
Phone: 248-624-4511