Provider Demographics
NPI:1144224700
Name:WILDERN, STEVEN GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:GEORGE
Last Name:WILDERN
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 1:1005 W GREEN ST
Mailing Address - Street 2:STE 201
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1726
Mailing Address - Country:US
Mailing Address - Phone:269-945-2419
Mailing Address - Fax:269-945-0357
Practice Address - Street 1:1005 W GREEN ST
Practice Address - Street 2:RM 301
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1729
Practice Address - Country:US
Practice Address - Phone:269-945-2419
Practice Address - Fax:269-945-0357
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISW039857174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICN0332OtherPALMETTO GBA RAILROAD
MI1340544Medicaid
MICN0332OtherPALMETTO GBA RAILROAD
MI0080001Medicare PIN