Provider Demographics
NPI:1932129319
Name:ADVANCED PHYSICAL MEDICINE, P.C.
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL MEDICINE, P.C.
Other - Org Name:ADVANCED PHYSICAL MEDICINE, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-563-3300
Mailing Address - Street 1:24345 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1231
Mailing Address - Country:US
Mailing Address - Phone:586-563-3300
Mailing Address - Fax:586-563-3313
Practice Address - Street 1:24345 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1231
Practice Address - Country:US
Practice Address - Phone:586-563-3300
Practice Address - Fax:586-563-3313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISW061846208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQMXPR0031827OtherMOLINA HEALTH CARE
MI00000004300AOtherCAPE HEALTH PLAN
MI578264ADVOtherUNITED HEALTH CARE
MI433225010Medicaid
MI116625OtherGREAT LAKES HEALTH PLAN
MI1932129319OtherDMENSION
MI199589OtherTOTAL HEALTH CARE
MI131109OtherCARE CHOICES
MI2505012031OtherBCBSM
MI540E019050OtherBCBSM DME
MI5614160001OtherMC NSC
MI5112550OtherAETNA
MI7908612OtherCIGNA
MI116625OtherGREAT LAKES HEALTH PLAN
MI433225010Medicaid