Provider Demographics
NPI:1457596223
Name:WELLNESS FAMILY PRACTICE P.C.
Entity Type:Organization
Organization Name:WELLNESS FAMILY PRACTICE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-892-7722
Mailing Address - Street 1:1003 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1234
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:2110 16TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7609
Practice Address - Country:US
Practice Address - Phone:989-892-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1457596223Medicaid
MI080Z901190OtherBCBS
MI1457596223Medicaid
MIMI1566Medicare PIN