Provider Demographics
NPI:1235456609
Name:ENVISION MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:ENVISION MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-348-8700
Mailing Address - Street 1:27275 HAGGERTY RD STE 500
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3635
Mailing Address - Country:US
Mailing Address - Phone:248-741-6901
Mailing Address - Fax:248-721-8203
Practice Address - Street 1:422 N CENTER ST
Practice Address - Street 2:SUITE B
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1224
Practice Address - Country:US
Practice Address - Phone:248-449-7156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6479210002Medicare NSC