Healthcare Provider Details

I. General information

NPI: 1851547434
Provider Name (Legal Business Name): WYANDOTTE PHYSICIAN PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1848 BIDDLE AVE SUITE 101
WYANDOTTE MI
48192-3962
US

IV. Provider business mailing address

PO BOX 674102
DETROIT MI
48267-0001
US

V. Phone/Fax

Practice location:
  • Phone: 734-284-2600
  • Fax: 734-284-2666
Mailing address:
  • Phone: 800-827-3797
  • Fax: 248-553-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN E KIBBLE
Title or Position: DIRECTOR
Credential:
Phone: 313-874-3436