Provider Demographics
NPI:1528382991
Name:ENVISION MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:ENVISION MEDICAL GROUP PLLC
Other - Org Name:ENVISION LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-348-8700
Mailing Address - Street 1:15100 MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17800 NEWBURGH RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2700
Practice Address - Country:US
Practice Address - Phone:734-464-9540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory