1336349802 NPI number — HEATHER WALTERS MD

Table of content: HEATHER WALTERS MD (NPI 1336349802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336349802 NPI number — HEATHER WALTERS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTERS
Provider First Name:
HEATHER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIDERHOLD
Provider Other First Name:
HEATHER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336349802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38935 ANN ARBOR RD
Provider Second Line Business Mailing Address:
CREDENTIALING/PAYER CONTRACTING
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48150-3397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-805-0477
Provider Business Mailing Address Fax Number:
866-250-6385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10000 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
EMERGENCY MEDICINE DEPARTMENT
Provider Business Practice Location Address City Name:
TAYLOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48180-3330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-295-5007
Provider Business Practice Location Address Fax Number:
313-295-6725
Provider Enumeration Date:
07/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  4301090081 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1336349802 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12130578 . This is a "CAQH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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