Basic Information
| Provider Information | |||||||||
| NPI: | 1073112819 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IHA OLMA PRIMARY NON RISK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR STE J2000 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343270872 | ||||||||
| FaxNumber: | 7342223100 | ||||||||
| Practice Location | |||||||||
| Address1: | 37595 7 MILE RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481521003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348535694 | ||||||||
| FaxNumber: | 7344309388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2020 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ELLIOTT | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & COO | ||||||||
| AuthorizedOfficialTelephone: | 7343270341 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.