Basic Information
| Provider Information | |||||||||
| NPI: | 1407814916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLEMEYER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4378 HOLT RD | ||||||||
| Address2: | |||||||||
| City: | HOLT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488421666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176941466 | ||||||||
| FaxNumber: | 5176943530 | ||||||||
| Practice Location | |||||||||
| Address1: | 4378 HOLT RD | ||||||||
| Address2: | |||||||||
| City: | HOLT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488421666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176941466 | ||||||||
| FaxNumber: | 5176943530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
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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 | 207Q00000X | TW044920 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | TW044920 | 01 | BCBSM | OTHER | 0100235 | 01 | MI | PHYSICIANS HEALTH PLAN OF | OTHER | 102805476 | 05 | MI | MEDICAID | TW044920 | 01 | BCN BLUE CARE NETWORK | OTHER | 0170235 | 01 | MI | PHYSICIANS HEALTH PLAN OF | OTHER |