=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861503237
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WL PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2449 E 12 MILE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48092-5647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-558-8435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2333 WAUKEGAN RD SUITE 175
-----------------------------------------------------
City | BANNOCKBURN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-267-0801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER/OFFICE MANAGER
-----------------------------------------------------
Name | MICHELLE YOUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-374-5316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------