Provider Demographics
NPI:1619928579
Name:WAHL, WAYNE S (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:S
Last Name:WAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2990 CAMPBELL RD
Mailing Address - Street 2:PO BOX 527
Mailing Address - City:ROSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48654-9724
Mailing Address - Country:US
Mailing Address - Phone:989-685-2333
Mailing Address - Fax:989-685-2760
Practice Address - Street 1:2990 CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:ROSE CITY
Practice Address - State:MI
Practice Address - Zip Code:48654-9724
Practice Address - Country:US
Practice Address - Phone:989-685-2333
Practice Address - Fax:989-685-2760
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08OG21014OtherBCBS
MI4737446Medicaid
MIP00258733OtherRAILROAD MEDICARE
MI4758830Medicaid
MI4758858Medicaid
MI4737419Medicaid
MI4737400Medicaid
MI4758858Medicaid
MI4737446Medicaid