Healthcare Provider Details

I. General information

NPI: 1508934043
Provider Name (Legal Business Name): MAX V. WISGERHOF II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 FRANK LLOYD WRIGHT DR LOBBY C SUITE 1300
ANN ARBOR MI
48105-9484
US

IV. Provider business mailing address

3621 SOUTH STATE STREET 700 KMS PLACE
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 734-647-5871
  • Fax:
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301039438
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number4301039438
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: