Provider Demographics
NPI:1144411091
Name:WAGNER, JOLYN WELSH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOLYN
Middle Name:WELSH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:999 HAYNES ST
Mailing Address - Street 2:SUITE 280
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6712
Mailing Address - Country:US
Mailing Address - Phone:248-258-9085
Mailing Address - Fax:
Practice Address - Street 1:999 HAYNES ST
Practice Address - Street 2:SUITE 280
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6712
Practice Address - Country:US
Practice Address - Phone:248-258-9085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2008-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010500482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE64398Medicare UPIN