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General NPI Number Information
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NPI Number | 1578891750
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Entity Type | Organization
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Legal Business Name | ENVISION MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 11/25/2009
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 42931 7 MILE RD
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City | NORTHVILLE
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State | MI
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Zip | 48167-2277
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Country | US
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Telephone | 248-348-8700
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 27420
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City | BELFAST
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State | ME
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Zip | 04915-2026
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MICHAEL WAYNE
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Credential | DO
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Telephone | 248-741-6909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 23D0368331
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License Number State | MI
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Taxonomy #6
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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