=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184121824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADFORD J WOELKE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 09/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | IHA CLARKSTON PRIMARY CARE 6770 DIXIE HIGHWAY SUITE 303
-----------------------------------------------------
City | CLARSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-625-0300
-----------------------------------------------------
Fax | 248-625-4403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-747-6766
-----------------------------------------------------
Fax | 734-222-3100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4301504633
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------