Basic Information
| Provider Information | |||||||||
| NPI: | 1134106024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43750 GARFIELD RD | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779969975 | ||||||||
| FaxNumber: | 5862284533 | ||||||||
| Practice Location | |||||||||
| Address1: | 21000 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ST CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864475100 | ||||||||
| FaxNumber: | 5864475090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301070798 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 4755678 | 05 | MI | MEDICAID | 0E01168 | 01 | MI | BCBS GROUP NUMBER | OTHER |