Provider Demographics
NPI:1013938455
Name:WOLVERINE ORTHOTICS, INC.
Entity Type:Organization
Organization Name:WOLVERINE ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNST
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:BASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:248-324-3010
Mailing Address - Street 1:28455 HAGGERTY RD
Mailing Address - Street 2:101
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2982
Mailing Address - Country:US
Mailing Address - Phone:248-324-3010
Mailing Address - Fax:248-324-3003
Practice Address - Street 1:28455 HAGGERTY RD
Practice Address - Street 2:101
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2982
Practice Address - Country:US
Practice Address - Phone:248-324-3010
Practice Address - Fax:248-324-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI510F312100OtherBCBSM
MI853203750Medicaid
MI510F312100OtherBCBSM