Provider Demographics
NPI:1689684490
Name:WYOMING FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:WYOMING FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIDENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-534-1640
Mailing Address - Street 1:950 36TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-3587
Mailing Address - Country:US
Mailing Address - Phone:616-534-1640
Mailing Address - Fax:616-534-4370
Practice Address - Street 1:950 36TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-3587
Practice Address - Country:US
Practice Address - Phone:616-534-1640
Practice Address - Fax:616-534-4370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16011OtherBC/BSM GROUP PROVIDER
MI0D16011OtherBC/BSM GROUP PROVIDER