Provider Demographics
NPI:1477729028
Name:PATRICK J WIATER MD,PLLC
Entity Type:Organization
Organization Name:PATRICK J WIATER MD,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-341-2440
Mailing Address - Street 1:17877 W FOURTEEN MILE RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025
Mailing Address - Country:US
Mailing Address - Phone:248-644-3920
Mailing Address - Fax:248-644-2569
Practice Address - Street 1:17877 W FOURTEEN MILE RD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025
Practice Address - Country:US
Practice Address - Phone:248-644-3920
Practice Address - Fax:248-644-2569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI067714207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4450577Medicaid
MION52120Medicare PIN
MIH00454Medicare UPIN