Healthcare Provider Details

I. General information

NPI: 1922072271
Provider Name (Legal Business Name): MIDTOWN FAMILY PRACTICE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E MAIN ST
BENTON HARBOR MI
49022-4409
US

IV. Provider business mailing address

129 E MAIN ST
BENTON HARBOR MI
49022-4409
US

V. Phone/Fax

Practice location:
  • Phone: 269-927-3828
  • Fax: 269-927-3829
Mailing address:
  • Phone: 269-927-3828
  • Fax: 269-927-3829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AMELIA WILSON
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 269-927-3828