Basic Information
| Provider Information | |||||||||
| NPI: | 1831771401 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IHA OOMA PRIMARY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR STE J2000 | ||||||||
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| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2630 UNION LAKE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | COMMERCE TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483823583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483601200 | ||||||||
| FaxNumber: | 2483606182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2021 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | ELLIOTT | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESDIENT / CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7343270341 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.