MEDICARE: WELLSTREET URGENT CARE OF MICHIGAN

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	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1417637471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSTREET URGENT CARE OF MICHIGAN

Provider Business Mailing Address
First Line	:	1825 HIGHWAY 34 E
Second Line	:
City	:	NEWNAN
State	:	GA
Zip	:	30265-6423
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6543 TELEGRAPH RD
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-3066
Country	:	US
Telephone Number	:	248-940-4937
Fax Number	:

Authorized Official
Title or Position	:	CGO
Name	:	LEE A RESNICK
Credential	:
Telephone Number	:	216-383-3480

Provider Enumeration Date	:	07/24/2023
Last Update Date	:	07/24/2023

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