MEDICARE: WHITMORE LAKE HEALTH CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician		MI

General Provider Information

NPI Number	:	1790901304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITMORE LAKE HEALTH CLINIC

Provider Business Mailing Address
First Line	:	9690 E MI STATE ROAD 36
Second Line	:	PO BOX 606
City	:	WHITMORE LAKE
State	:	MI
Zip	:	48189-9703
Country	:	US
Telephone Number	:	734-449-2033
Fax Number	:	734-449-7186

Provider Business Practice Location Address
First Line	:	9690 E MI STATE ROAD 36
Second Line	:
City	:	WHITMORE LAKE
State	:	MI
Zip	:	48189-9703
Country	:	US
Telephone Number	:	734-449-2033
Fax Number	:	734-449-7186

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. HILDA M. ELY
Credential	:
Telephone Number	:	734-449-2033

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	08/22/2020

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