Provider Demographics
NPI:1932169018
Name:WILHELM, KENNETH GEORGE SR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GEORGE
Last Name:WILHELM
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 MCAULEY DR
Mailing Address - Street 2:SUITE R-5017
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1014
Mailing Address - Country:US
Mailing Address - Phone:734-434-2490
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE R-5017
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:734-434-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028204208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1983615Medicaid
MI1983615Medicaid
MIB47227Medicare UPIN