Provider Demographics
NPI:1508875840
Name:PROVISIONS HEALTH
Entity Type:Organization
Organization Name:PROVISIONS HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-346-7628
Mailing Address - Street 1:9557 S AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2522 GOLF RD STE 2
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6033
Practice Address - Country:US
Practice Address - Phone:715-833-0660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2022-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013727207Q00000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI22-76363OtherMEDICAL LICENSE
MIBW6551938OtherDEA NUMBER
MI0853310215OtherBLUE CROSS
MI0853310215OtherBLUE CROSS
MI0N88590Medicare ID - Type Unspecified