MEDICARE: MISS ROSANNE KAY WILD MSW

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	104100000X	Social Worker	6801077649	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8008974760	OTHER	MI	BLUE CROSS

General Provider Information

NPI Number	:	1225129372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ROSANNE KAY WILD MSW

Provider Business Mailing Address
First Line	:	1417 FRASER ST
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48708-7957
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1513 COLUMBUS AVE
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48708-6824
Country	:	US
Telephone Number	:	989-778-4993
Fax Number	:

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

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	08/28/2024

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