Provider Demographics
NPI:1003083957
Name:PETER L WICKENS D.O.,P.C.
Entity Type:Organization
Organization Name:PETER L WICKENS D.O.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-293-2088
Mailing Address - Street 1:14050 E 14 MILE RD
Mailing Address - Street 2:WARREN
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-5765
Mailing Address - Country:US
Mailing Address - Phone:586-293-2088
Mailing Address - Fax:586-293-5502
Practice Address - Street 1:14050 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-5765
Practice Address - Country:US
Practice Address - Phone:586-293-2088
Practice Address - Fax:586-293-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006061261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI55026827011Medicare PIN
MIE26517Medicare UPIN