Healthcare Provider Details

I. General information

NPI: 1316086887
Provider Name (Legal Business Name): DARYL WISDOM MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10015 CASCADE RD SE
LOWELL MI
49331-9529
US

IV. Provider business mailing address

10015 CASCADE RD SE
LOWELL MI
49331-9529
US

V. Phone/Fax

Practice location:
  • Phone: 616-868-7551
  • Fax: 616-868-7321
Mailing address:
  • Phone: 616-868-7551
  • Fax: 616-868-7321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number4301048819
License Number StateMI

VIII. Authorized Official

Name: DR. DARYL WISDOM
Title or Position: OWNER
Credential: MD
Phone: 616-868-7551