=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053120022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH WILTON HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2025
-----------------------------------------------------
Last Update Date | 01/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 S SCOTT RD
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48879-8044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-224-8936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4425 N AIRPORT RD
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48879-9780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-640-2788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JACOB MICHAEL MONESTERSKY
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 989-640-2788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------