Healthcare Provider Details

I. General information

NPI: 1144224700
Provider Name (Legal Business Name): STEVEN GEORGE WILDERN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 W GREEN ST RM 301
HASTINGS MI
49058-1729
US

IV. Provider business mailing address

1005 W GREEN ST STE 201
HASTINGS MI
49058-1726
US

V. Phone/Fax

Practice location:
  • Phone: 269-945-2419
  • Fax: 269-945-0357
Mailing address:
  • Phone: 269-945-2419
  • Fax: 269-945-0357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberSW039857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: