Provider Demographics
NPI:1356566947
Name:WYANDOTTE MEDICAL PRACTICES
Entity type:Organization
Organization Name:WYANDOTTE MEDICAL PRACTICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-246-6044
Mailing Address - Street 1:PO BOX 674102
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-4102
Mailing Address - Country:US
Mailing Address - Phone:734-324-3912
Mailing Address - Fax:734-324-3976
Practice Address - Street 1:1640 FORT ST
Practice Address - Street 2:SUITE D
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2040
Practice Address - Country:US
Practice Address - Phone:734-671-6741
Practice Address - Fax:734-671-1038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N64300Medicare PIN