Provider Demographics
NPI:1164415733
Name:WILCENSKI, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WILCENSKI
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:P.O. BOX 415750
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:02241-5750
Mailing Address - Country:US
Mailing Address - Phone:908-851-8602
Mailing Address - Fax:908-686-8758
Practice Address - Street 1:695 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083
Practice Address - Country:US
Practice Address - Phone:908-851-8602
Practice Address - Fax:908-851-8758
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06250900207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6581404Medicaid
NJ6581404Medicaid
NJG12262Medicare UPIN