Provider Demographics
NPI:1457544017
Name:EUGENE P WANG, DO PC
Entity Type:Organization
Organization Name:EUGENE P WANG, DO PC
Other - Org Name:HARBORSIDE SPINE & SPORTS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENSCHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-348-3283
Mailing Address - Street 1:2375 SUMMIT PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:231-348-3283
Mailing Address - Fax:231-348-3331
Practice Address - Street 1:2375 SUMMIT PARK DR
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8685
Practice Address - Country:US
Practice Address - Phone:231-348-3283
Practice Address - Fax:231-348-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI077046208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI250012416Medicare PIN
MIH05546Medicare UPIN