Provider Demographics
NPI:1942407705
Name:CRAIG D. WENDT, M.D.
Entity Type:Organization
Organization Name:CRAIG D. WENDT, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:D
Authorized Official - Last Name:WENDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-547-2812
Mailing Address - Street 1:14695 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1929
Mailing Address - Country:US
Mailing Address - Phone:231-547-2812
Mailing Address - Fax:231-547-3067
Practice Address - Street 1:14695 PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1929
Practice Address - Country:US
Practice Address - Phone:231-547-2812
Practice Address - Fax:231-547-3067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3923873Medicaid
MIB47543Medicare UPIN