Provider Demographics
NPI:1851547434
Name:WYANDOTTE PHYSICIAN PRACTICES
Entity Type:Organization
Organization Name:WYANDOTTE PHYSICIAN PRACTICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-874-3436
Mailing Address - Street 1:PO BOX 674102
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0001
Mailing Address - Country:US
Mailing Address - Phone:800-827-3797
Mailing Address - Fax:248-553-2108
Practice Address - Street 1:1848 BIDDLE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-3962
Practice Address - Country:US
Practice Address - Phone:734-284-2600
Practice Address - Fax:734-284-2666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty