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General NPI Number Information
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NPI Number | 1891711362
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Entity Type | Individual
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Provider Name | MICHELLE I CERVIN -WAGNER DO
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Gender | Female
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Dates
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Enumeration Date | 07/15/2006
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Last Update Date | 02/24/2025
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Provider Practice Location Address
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Address Line | 320 S DR MARTIN LUTHER KING JR BLVD STE 300
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City | SOUTH BEND
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State | IN
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Zip | 46601-2358
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Country | US
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Telephone | 574-406-6376
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Fax | 574-406-6377
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Provider Business Mailing Address
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Address Line | 14504 DOUGLAS RD
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City | MISHAWAKA
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State | IN
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Zip | 46545-1709
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Country | US
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Telephone | 574-344-0479
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5101011099
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 02001685
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License Number State | IN
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