Provider Demographics
NPI:1477621068
Name:WILSHIRE OBSTETRIC & GYNECOLOGIC ASSOCIATES
Entity Type:Organization
Organization Name:WILSHIRE OBSTETRIC & GYNECOLOGIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MILLARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOLUSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-267-5040
Mailing Address - Street 1:13467 23 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-2717
Mailing Address - Country:US
Mailing Address - Phone:248-267-5040
Mailing Address - Fax:248-267-5041
Practice Address - Street 1:13467 23 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-2717
Practice Address - Country:US
Practice Address - Phone:248-267-5040
Practice Address - Fax:248-267-5041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMG039013207V00000X
MI4301063722207V00000X
MI4301077870207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1288220Medicaid
N96510002Medicare ID - Type Unspecified
G84224Medicare UPIN
B47288Medicare UPIN
MI1288220Medicaid
MIN96510003Medicare ID - Type Unspecified
MIN96510001Medicare ID - Type Unspecified