MEDICARE: OUTPATIENT WOUND SOLUTIONS, INC.

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	207Q00000X	Family Medicine Physician	20A10786	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194017426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUTPATIENT WOUND SOLUTIONS, INC.

Provider Business Mailing Address
First Line	:	607 ELMIRA RD
Second Line	:	SUITE 165
City	:	VACAVILLE
State	:	CA
Zip	:	95687-4655
Country	:	US
Telephone Number	:	707-999-0242
Fax Number	:

Provider Business Practice Location Address
First Line	:	607 ELMIRA RD
Second Line	:	SUITE 165
City	:	VACAVILLE
State	:	CA
Zip	:	95687-4655
Country	:	US
Telephone Number	:	707-999-0242
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRIAN THOMAS MICHALUK
Credential	:	DO
Telephone Number	:	707-999-0242

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	04/05/2012

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