Provider Demographics
NPI:1013117670
Name:WYANDOTTE MEDICAL PRACTICES
Entity type:Organization
Organization Name:WYANDOTTE MEDICAL PRACTICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-874-3436
Mailing Address - Street 1:3333 BIDDLE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-6284
Mailing Address - Country:US
Mailing Address - Phone:734-671-3248
Mailing Address - Fax:734-671-1819
Practice Address - Street 1:3851 WEST RD
Practice Address - Street 2:SUITE 1
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2350
Practice Address - Country:US
Practice Address - Phone:734-671-3248
Practice Address - Fax:734-671-1819
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYANDOTTE MEDICAL PRACTICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015620207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty