Provider Demographics
NPI:1255319729
Name:WESEN, CHERYL A (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:WESEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19229 MACK AVE
Mailing Address - Street 2:STE 34
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2858
Mailing Address - Country:US
Mailing Address - Phone:313-647-3912
Mailing Address - Fax:313-647-3902
Practice Address - Street 1:19229 MACK AVE
Practice Address - Street 2:STE 34
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2858
Practice Address - Country:US
Practice Address - Phone:313-647-3912
Practice Address - Fax:313-347-3902
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062525208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3475787Medicaid
MI4816915Medicaid
MI0H231320OtherBLUE CROSS GROUP
MI4816915Medicaid
MI0H231320OtherBLUE CROSS GROUP
F69606Medicare UPIN