Provider Demographics
NPI:1790989317
Name:GEORGE, WISAM (DO)
Entity Type:Individual
Prefix:DR
First Name:WISAM
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:32255 NORTHWESTERN HWY STE 165
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1505
Mailing Address - Country:US
Mailing Address - Phone:248-735-8272
Mailing Address - Fax:248-735-7276
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:SUITE 2100
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-624-7246
Practice Address - Fax:248-624-2597
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315031019207LP2900X
MIL1130895207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty