Provider Demographics
NPI:1568419240
Name:SENIORS WELLNESS GROUP, P.C.
Entity Type:Organization
Organization Name:SENIORS WELLNESS GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOTLARZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-398-6459
Mailing Address - Street 1:221 S MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2611
Mailing Address - Country:US
Mailing Address - Phone:248-398-6459
Mailing Address - Fax:
Practice Address - Street 1:221 S MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2611
Practice Address - Country:US
Practice Address - Phone:248-398-6459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOMO6670Medicare ID - Type UnspecifiedPSYCHOLOLGISTS
MI0N31030Medicare ID - Type UnspecifiedPHYSICIANS ASSISTANTS
MI0M88490Medicare ID - Type UnspecifiedPSYCHIATRISTS
MI0M39070Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKERS
MI0N49580Medicare ID - Type UnspecifiedNURSE PRACTITIONERS