Provider Demographics
NPI:1518261957
Name:WYANDOTTE MEDICAL PRACTICE
Entity Type:Organization
Organization Name:WYANDOTTE MEDICAL PRACTICE
Other - Org Name:NORTHLINE WOMANS HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR OUTPATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-246-8803
Mailing Address - Street 1:15675 NORTHLINE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2334
Mailing Address - Country:US
Mailing Address - Phone:734-282-3600
Mailing Address - Fax:734-282-3603
Practice Address - Street 1:15675 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2334
Practice Address - Country:US
Practice Address - Phone:734-282-3600
Practice Address - Fax:734-282-3603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty