Healthcare Provider Details

I. General information

NPI: 1437735412
Provider Name (Legal Business Name): HARRISON ROSS WERMUTH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 04/13/2025
Certification Date: 04/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1896
US

IV. Provider business mailing address

1013 E 2ND ST
ROYAL OAK MI
48067-2842
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 248-762-9217
  • Fax: 888-574-7413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101028127
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.017598
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02008198A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number331213
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: