Provider Demographics
NPI:1710998505
Name:WYBENGA FAMILY HEALTHCARE, INC.
Entity Type:Organization
Organization Name:WYBENGA FAMILY HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAARTEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYBENGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-358-2010
Mailing Address - Street 1:2257 TAYLOR RD
Mailing Address - Street 2:200
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7790
Mailing Address - Country:US
Mailing Address - Phone:334-270-9914
Mailing Address - Fax:334-270-3195
Practice Address - Street 1:564 N MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-2132
Practice Address - Country:US
Practice Address - Phone:334-358-2010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALK791Medicare PIN