Provider Demographics
NPI:1598840910
Name:WYANDOTTE INTERNAL MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:WYANDOTTE INTERNAL MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAYLEY
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-284-2026
Mailing Address - Street 1:1700 BIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-7205
Mailing Address - Country:US
Mailing Address - Phone:734-284-2026
Mailing Address - Fax:734-284-7424
Practice Address - Street 1:1700 BIDDLE ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-7205
Practice Address - Country:US
Practice Address - Phone:734-284-2026
Practice Address - Fax:734-284-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M95480Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER