Provider Demographics
NPI:1629263520
Name:WESTERN WAYNE FAMILY PHYSICIANS, PLC
Entity Type:Organization
Organization Name:WESTERN WAYNE FAMILY PHYSICIANS, PLC
Other - Org Name:WESTERN WAYNE PHYSICIANS, PLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-386-5500
Mailing Address - Street 1:7445 ALLEN RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1963
Mailing Address - Country:US
Mailing Address - Phone:313-386-5500
Mailing Address - Fax:313-386-3444
Practice Address - Street 1:7445 ALLEN RD
Practice Address - Street 2:SUITE 250
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1963
Practice Address - Country:US
Practice Address - Phone:313-386-5500
Practice Address - Fax:313-386-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3506382Medicaid
MI4172620Medicaid
MI4545062Medicaid
MI4172611Medicaid
MICD8151OtherRAILROAD MEDICARE
MICC4542OtherRAILROAD MEDICARE
MI4545053Medicaid
MI4281910Medicaid
MI4572954Medicaid
MICG3535OtherRAILROAD MEDICARE
MI4545062Medicaid
MI4572954Medicaid