Provider Demographics
NPI:1740261684
Name:WILES, STEVEN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:THOMAS
Last Name:WILES
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 S STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3637
Mailing Address - Country:US
Mailing Address - Phone:906-774-5800
Mailing Address - Fax:906-228-0200
Practice Address - Street 1:5629 STADIUM DR STE A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1952
Practice Address - Country:US
Practice Address - Phone:269-372-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93-00374208000000X
MI4301116553208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7987350Medicaid
NC7987350Medicaid