Provider Demographics
NPI:1316203102
Name:WYANDOTTE PHYSICIAN PRACTICES
Entity Type:Organization
Organization Name:WYANDOTTE PHYSICIAN PRACTICES
Other - Org Name:DOWNRIVER INTERNIST PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHYSICIAN PRACTICES
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-391-3057
Mailing Address - Street 1:1640 FORT STREET
Mailing Address - Street 2:SUITE D ATTN DENISE
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183
Mailing Address - Country:US
Mailing Address - Phone:734-391-3057
Mailing Address - Fax:734-391-3052
Practice Address - Street 1:15450 NORTHLINE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2490
Practice Address - Country:US
Practice Address - Phone:734-224-3679
Practice Address - Fax:734-287-9926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID