=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235350331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WYANDOTTE MEDICAL PRACTICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 10/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3333 BIDDLE AVE SUITE B
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-282-8650
-----------------------------------------------------
Fax | 734-282-8651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3333 BIDDLE ST SUITE C
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192-6284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-282-8650
-----------------------------------------------------
Fax | 734-282-8651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MATTHEW WOLOCKO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-324-3591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------