Provider Demographics
NPI:1679883672
Name:WYANDOTTE PHYSICIAN PRACTICES
Entity Type:Organization
Organization Name:WYANDOTTE PHYSICIAN PRACTICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR, OUTPATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANCTIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-246-8803
Mailing Address - Street 1:PO BOX 674102
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-4102
Mailing Address - Country:US
Mailing Address - Phone:734-284-4309
Mailing Address - Fax:734-671-1405
Practice Address - Street 1:23050 WEST RD
Practice Address - Street 2:STE 260
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1472
Practice Address - Country:US
Practice Address - Phone:734-284-4309
Practice Address - Fax:734-671-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-12
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty