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General NPI Number Information
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NPI Number | 1245125053
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Entity Type | Individual
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Provider Name | WILLIE JAMES MCCONICO JR. GENERALIST
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Gender | Male
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Dates
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Enumeration Date | 06/11/2025
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Last Update Date | 06/11/2025
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Provider Practice Location Address
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Address Line | 1605 FORT ST
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City | LINCOLN PARK
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State | MI
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Zip | 48146-1915
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Country | US
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Telephone | 313-382-7861
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Fax |
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Provider Business Mailing Address
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Address Line | 29125 ROSEWOOD ST
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City | INKSTER
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State | MI
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Zip | 48141-1677
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Country | US
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Telephone | 734-363-0934
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State |
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