Provider Demographics
NPI:1386642056
Name:WISSMAN, SHERYL A (MD)
Entity Type:Individual
Prefix:DR
First Name:SHERYL
Middle Name:A
Last Name:WISSMAN
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 1:72 S WASHINGTON ST
Mailing Address - Street 2:STE 204
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6421
Mailing Address - Country:US
Mailing Address - Phone:248-628-2233
Mailing Address - Fax:248-628-2384
Practice Address - Street 1:72 S WASHINGTON ST
Practice Address - Street 2:SUITE 204
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6421
Practice Address - Country:US
Practice Address - Phone:248-628-2233
Practice Address - Fax:248-628-2384
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051927207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4406452Medicaid
MI700F37550OtherBCBSM
MIM89900070Medicare PIN
MI700F37550OtherBCBSM