=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083647739
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETER M WILUSZ DPM PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 06/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5730 BELLA ROSA BLVD STE 200
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-922-6000
-----------------------------------------------------
Fax | 248-922-5779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5730 BELLA ROSA BLVD STE 200
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48348-4774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-922-6000
-----------------------------------------------------
Fax | 248-922-5779
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PETER M WILUSZ
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 248-672-8805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 5901002033
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------