=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023223955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERBERT WEISENTHAL, D.O., P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29829 TELEGRAPH RD SUITE L-102
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-352-3790
-----------------------------------------------------
Fax | 248-352-9712
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29829 TELEGRAPH RD SUITE L-102
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-352-3790
-----------------------------------------------------
Fax | 248-352-9712
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HERBERT WEISENTHAL
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 248-352-3790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 5101005690
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------