Provider Demographics
NPI:1730177783
Name:WEATHERHEAD, JAMES L (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:WEATHERHEAD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1005 W GREEN ST
Mailing Address - Street 2:SUITE G100
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1712
Mailing Address - Country:US
Mailing Address - Phone:269-948-7820
Mailing Address - Fax:269-948-2458
Practice Address - Street 1:1005 W GREEN ST
Practice Address - Street 2:SUITE G100
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1712
Practice Address - Country:US
Practice Address - Phone:269-948-7820
Practice Address - Fax:269-948-2458
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2009-01-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301032093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080058179OtherRAILROAD MEDICARE
MI0800822151OtherBLUE CROSS BLUE SHIELD
MI209975510Medicaid
MI0800822151OtherBLUE CARE NETWORK
MI0082215Medicare PIN
MI080058179OtherRAILROAD MEDICARE
MI209975510Medicaid