Provider Demographics
NPI:1891711362
Name:CERVIN -WAGNER, MICHELLE I (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:I
Last Name:CERVIN -WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:I
Other - Last Name:CERVIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 E CHICAGO RD
Practice Address - Street 2:
Practice Address - City:WHITE PIGEON
Practice Address - State:MI
Practice Address - Zip Code:49099-9731
Practice Address - Country:US
Practice Address - Phone:269-483-7624
Practice Address - Fax:269-483-7905
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011099207Q00000X
IN02001685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1891711362Medicaid