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General NPI Number Information
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NPI Number | 1821043399
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Entity Type | Organization
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Legal Business Name | THEODORE A. WIZENBERG, M.D.,P.C.
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 10/23/2007
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Provider Practice Location Address
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Address Line | 23901 LAHSER RD
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City | SOUTHFIELD
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State | MI
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Zip | 48033-6035
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Country | US
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Telephone | 248-357-3360
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Fax |
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Provider Business Mailing Address
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Address Line | 31151 WESTWOOD RD
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City | FARMINGTON HILLS
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State | MI
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Zip | 48331-1471
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Country | US
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Telephone | 248-661-9125
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THEODORE A WIZENBERG
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Credential | M.D.
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Telephone | 248-661-9125
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | TW038081
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License Number State | MI
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