Provider Demographics
NPI:1033179924
Name:WURTZ, RANDALL T (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:T
Last Name:WURTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23800 ORCHARD LAKE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-2561
Mailing Address - Country:US
Mailing Address - Phone:248-476-2420
Mailing Address - Fax:248-476-9709
Practice Address - Street 1:23800 ORCHARD LAKE RD
Practice Address - Street 2:STE 100
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-2561
Practice Address - Country:US
Practice Address - Phone:248-476-2420
Practice Address - Fax:248-476-9709
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRW04811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0630509OtherBCBS
MI3396093Medicaid
C4937OtherMCARE
103911OtherCARE CHOICES PREFERRED CH
A76102Medicare UPIN