Basic Information
| Provider Information | |||||||||
| NPI: | 1679553952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYHARTLE | ||||||||
| FirstName: | THERESA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 12805 ESCANABA DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | DEWITT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488208628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173675520 | ||||||||
| FaxNumber: | 5173675521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 5101011364 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 252503 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | 01795 | 01 | MI | AETNA | OTHER | 0700186 | 01 | MI | PHYSICIANS HEALTH PLAN | OTHER | 252503 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 1651913484 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 4154702 | 05 | MI | MEDICAID | G10710 | 01 | MI | HEALTH NET FEDERAL SERVIC | OTHER |