Healthcare Provider Details

I. General information

NPI: 1578891750
Provider Name (Legal Business Name): ENVISION MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2009
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42931 7 MILE RD
NORTHVILLE MI
48167-2277
US

IV. Provider business mailing address

PO BOX 27420
BELFAST ME
04915-2026
US

V. Phone/Fax

Practice location:
  • Phone: 248-348-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number23D0368331
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHAEL WAYNE
Title or Position: MANAGING MEMBER
Credential: DO
Phone: 248-741-6909