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General NPI Number Information
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NPI Number | 1124246228
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Entity Type | Organization
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Legal Business Name | WYANDOTTE MEDICAL PRACTICES
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 11/12/2008
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Provider Practice Location Address
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Address Line | 3333 BIDDLE ST STE C
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City | WYANDOTTE
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State | MI
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Zip | 48192-6284
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Country | US
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Telephone | 734-285-7420
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Fax | 734-285-7386
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Provider Business Mailing Address
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Address Line | 3333 BIDDLE ST STE C
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City | WYANDOTTE
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State | MI
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Zip | 48192-6284
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Country | US
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Telephone | 734-285-7420
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Fax | 734-285-7386
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Authorized Official
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Title or Position | DIRECTOR
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Name | MATTHEW WOLOCKO
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Credential |
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Telephone | 734-324-3591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 4301063383
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License Number State | MI
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