Provider Demographics
NPI:1477754604
Name:MIDWEST WOUND CARE ASSOCIATES, PC
Entity Type:Organization
Organization Name:MIDWEST WOUND CARE ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERGREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-228-4090
Mailing Address - Street 1:22550 LAW ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1087
Mailing Address - Country:US
Mailing Address - Phone:313-228-4090
Mailing Address - Fax:313-565-9827
Practice Address - Street 1:22550 LAW ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1087
Practice Address - Country:US
Practice Address - Phone:313-228-4090
Practice Address - Fax:313-565-9827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046893208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty