Provider Demographics
NPI:1164402772
Name:WASIELEWSKI, PAUL G (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:WASIELEWSKI
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 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:
Practice Address - Street 1:2122 HEALTH DRIVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-252-5790
Practice Address - Fax:616-252-5793
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350699372084N0400X
MI43010613552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16078467Medicaid
MI1164402772Medicaid
MICK6240OtherRAILROAD MEDICARE
OH0272084Medicaid
MICK6240OtherRAILROAD MEDICARE