MEDICARE: MICHAEL WOWK 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	390200000X	Student in an Organized Health Care Education/Training Program	W200603847817	MI
2	207Q00000X	Family Medicine Physician	4301110124	MI

General Provider Information

NPI Number	:	1366805210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL WOWK M.D.

Provider Business Mailing Address
First Line	:	15835 ANGELO LN
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-1601
Country	:	US
Telephone Number	:	586-942-1617
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 S CANTON CENTER RD STE 220
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-6276
Country	:	US
Telephone Number	:	734-398-8790
Fax Number	:	734-398-8680

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

Provider Enumeration Date	:	03/29/2016
Last Update Date	:	05/14/2019

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