Provider Demographics
NPI:1225280407
Name:RICHARD A. WANDZEL, DO PC
Entity Type:Organization
Organization Name:RICHARD A. WANDZEL, DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WANDZEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-889-7600
Mailing Address - Street 1:222 W HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48357-4504
Mailing Address - Country:US
Mailing Address - Phone:248-889-7600
Mailing Address - Fax:248-889-5876
Practice Address - Street 1:222 W HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357-4504
Practice Address - Country:US
Practice Address - Phone:248-889-7600
Practice Address - Fax:248-889-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008319207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1751002Medicaid
MI0456301784OtherBLUE CROSS
MI040F370330OtherBCBSM
MI0456301784OtherBLUE CROSS
MI1751002Medicaid
MI5630178Medicare PIN