Healthcare Provider Details

I. General information

NPI: 1629799630
Provider Name (Legal Business Name): MICHAEL WYNNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 PENNSYLVANIA AVE NW
WASHINGTON DC
20037-3201
US

IV. Provider business mailing address

312 SHOREWARD DR
MYRTLE BEACH SC
29579-5148
US

V. Phone/Fax

Practice location:
  • Phone: 202-741-3100
  • Fax:
Mailing address:
  • Phone: 203-446-1113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: