MEDICARE: PSYCHIATRIC PHYSICIANS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0015X	Psychosomatic Medicine Physician	4301066579	MI
2	2084P0800X	Psychiatry Physician	4301066579	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PTANON10230	OTHER	MI	PTAN ON10230

General Provider Information

NPI Number	:	1982824512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHIATRIC PHYSICIANS, PLLC

Provider Business Mailing Address
First Line	:	P.O. BOX 334
Second Line	:
City	:	GRAND HAVEN
State	:	MI
Zip	:	49417
Country	:	US
Telephone Number	:	231-798-8337
Fax Number	:	231-798-9816

Provider Business Practice Location Address
First Line	:	4461 GRAND HAVEN ROAD
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441
Country	:	US
Telephone Number	:	231-798-8337
Fax Number	:	231-798-9816

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. JAMES PATRICK WIADUCK
Credential	:	M.D.
Telephone Number	:	231-798-8337

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	01/08/2020

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