Provider Demographics
NPI:1104851658
Name:WISNIEWSKI, STEVEN JOHN (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:JOHN
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:271 MCCOY RD W
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-8253
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:829 N CENTER AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1595
Practice Address - Country:US
Practice Address - Phone:989-731-7870
Practice Address - Fax:989-731-7837
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430150548207RG0300X
MI4301050548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
381303843OtherTAX ID
MI4619513Medicaid
11292239OtherCAQH PROVIDER ID
MI0F96004016OtherMEDICARE PTAN
MI1101507782OtherBCBSM PROVIDER NUMBER
CC4805OtherMEDICARE RR PROV ID
B44110Medicare UPIN