Provider Demographics
NPI:1346353224
Name:WANIS, MAGDY GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:MAGDY
Middle Name:GEORGE
Last Name:WANIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23600 HARPER AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080
Mailing Address - Country:US
Mailing Address - Phone:586-585-2570
Mailing Address - Fax:586-585-2574
Practice Address - Street 1:23600 HARPER AVE
Practice Address - Street 2:STE 103
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-585-2570
Practice Address - Fax:586-585-2574
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMW065519207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G89641OtherHAP
P00051536OtherMEDICARE RR
FL912517500Medicaid
P105025OtherBCN
1105007952OtherBCBS
127679OtherCARE CHOICES
7189170OtherAETNA
C7549OtherMCARE
MI4243830Medicaid
7189170OtherAETNA
G89641Medicare UPIN