Provider Demographics
NPI:1700054210
Name:JOHANNA J VERWILGHEN MD PLLC
Entity Type:Organization
Organization Name:JOHANNA J VERWILGHEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:JACOBA
Authorized Official - Last Name:VERWILGHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-831-1100
Mailing Address - Street 1:4160 JOHN R ST
Mailing Address - Street 2:SUITE 525
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2020
Mailing Address - Country:US
Mailing Address - Phone:313-831-1100
Mailing Address - Fax:313-831-1177
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 525
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-831-1100
Practice Address - Fax:313-831-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077528207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108235412OtherBCBS
MI1108235412OtherBSBC
MN0P04790Medicare PIN
MI1108235412OtherBCBS