Provider Demographics
NPI:1235350331
Name:WYANDOTTE MEDICAL PRACTICES
Entity Type:Organization
Organization Name:WYANDOTTE MEDICAL PRACTICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLOCKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-324-3591
Mailing Address - Street 1:3333 BIDDLE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-6284
Mailing Address - Country:US
Mailing Address - Phone:734-282-8650
Mailing Address - Fax:734-282-8651
Practice Address - Street 1:3333 BIDDLE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192
Practice Address - Country:US
Practice Address - Phone:734-282-8650
Practice Address - Fax:734-282-8651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD2881OtherMEDICARE RAILROAD
0P15630Medicare PIN