Healthcare Provider Details

I. General information

NPI: 1104985001
Provider Name (Legal Business Name): CERTIFIED EMERGENCY MEDICINE SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BYRON CENTER AVE SW
WYOMING MI
49519
US

IV. Provider business mailing address

PO BOX 72011
CLEVELAND OH
44192-0002
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-7867
  • Fax: 616-363-9432
Mailing address:
  • Phone: 616-363-7867
  • Fax: 616-363-9432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: MRS. SONYA D WILSON
Title or Position: PROVIDER CREDENTIALING
Credential:
Phone: 616-363-7867