MEDICARE: DR. JAMES PATRICK WIADUCK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0805X	Geriatric Psychiatry Physician	4301066579	MI
2	2084P0800X	Psychiatry Physician	4301066579	MI

General Provider Information

NPI Number	:	1114946506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES PATRICK WIADUCK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 334
Second Line	:
City	:	GRAND HAVEN
State	:	MI
Zip	:	49417-0334
Country	:	US
Telephone Number	:	231-798-8337
Fax Number	:	231-798-9816

Provider Business Practice Location Address
First Line	:	4461 GRAND HAVEN RD
Second Line	:
City	:	NORTON SHORES
State	:	MI
Zip	:	49441-5548
Country	:	US
Telephone Number	:	231-798-8337
Fax Number	:	231-798-9816

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	01/02/2020

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