MEDICARE: THE WELLNESS PLAN MEDICAL CENTERS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	103T00000X	Psychologist
3	122300000X	Dentist
4	163WG0000X	General Practice Registered Nurse
5	207R00000X	Internal Medicine Physician
6	363L00000X	Nurse Practitioner
7	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PENDING	OTHER	MI	PER WPS
2	1235651381	OTHER		PER WPS

General Provider Information

NPI Number	:	1235651381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WELLNESS PLAN MEDICAL CENTERS

Provider Business Mailing Address
First Line	:	7700 2ND AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-2477
Country	:	US
Telephone Number	:	313-202-8660
Fax Number	:	313-202-8653

Provider Business Practice Location Address
First Line	:	46156 WOODWARD AVE
Second Line	:
City	:	PONTIAC
State	:	MI
Zip	:	48342-5033
Country	:	US
Telephone Number	:	248-897-0900
Fax Number	:	248-858-6499

Authorized Official
Title or Position	:	CEO & EXECUTIVE DIRECTOR
Name	:	ANTHONY V KING
Credential	:
Telephone Number	:	313-202-8550

Provider Enumeration Date	:	07/11/2017
Last Update Date	:	08/13/2020

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Directions to “THE WELLNESS PLAN MEDICAL CENTERS ” Practice Location

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