Basic Information
| Provider Information | |||||||||
| NPI: | 1487750022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHATLEY | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646253 | ||||||||
| FaxNumber: | 5173646204 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 E MICHIGAN AVE | ||||||||
| Address2: | STE 530 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173645880 | ||||||||
| FaxNumber: | 5173645887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 12/31/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301082788 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4609384 | 05 | MI | MEDICAID | 1103311021 | 01 | MI | BCBS INDIVIDUAL PIN | OTHER | 4922730 | 05 | MI | MEDICAID |